Public Act 097-0972
 
SB0679 EnrolledLRB097 04947 ASK 44987 b



    AN ACT concerning regulation.

 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:

 
    Section 5. The Illinois Insurance Code is amended  by 
changing Sections 356z.14 and 356z.16 as follows:
 
    (215 ILCS 5/356z.14)
    Sec. 356z.14. Autism spectrum disorders.
    (a)  A group or individual policy of accident and health 
insurance or managed care plan amended, delivered, issued, or 
renewed after the effective date of this amendatory Act of the 
95th General Assembly must provide individuals under 21 years 
of age coverage for the diagnosis of autism spectrum disorders 
and for the treatment of autism spectrum disorders to the 
extent that the diagnosis and treatment of autism spectrum 
disorders are not already covered by the policy of accident and 
health insurance or managed care plan.
    (b) Coverage provided under this Section shall be subject 
to a maximum benefit of $36,000 per year, but shall not be 
subject to any limits on the number of visits to a service 
provider. After December 30, 2009, the Director of the Division 
of Insurance shall, on an annual basis, adjust the maximum 
benefit for inflation using the Medical Care Component of the 
United States Department of Labor Consumer Price Index for All 
Urban Consumers.  Payments made by an insurer on behalf of a 
covered individual for any care, treatment, intervention, 
service, or item, the provision of which was for the treatment 
of a health condition not diagnosed as an autism spectrum 
disorder, shall not be applied toward any maximum benefit 
established under this subsection.
    (c) Coverage under this Section shall be subject to 
copayment, deductible, and coinsurance provisions of a policy 
of accident and health insurance or managed care plan to the 
extent that other medical services covered by the policy of 
accident and health insurance or managed care plan are subject 
to these provisions.
    (d)  This Section shall not be construed as limiting 
benefits that are otherwise available to an individual under a 
policy of accident and health insurance or managed care plan 
and benefits provided under this Section may not be subject to 
dollar limits, deductibles, copayments, or coinsurance 
provisions that are less favorable to the insured than the 
dollar limits, deductibles, or coinsurance provisions that 
apply to physical illness generally.
    (e) An insurer may not deny or refuse to provide otherwise 
covered services, or refuse to renew, refuse to reissue, or 
otherwise terminate or restrict coverage under an individual 
contract to provide services to an individual because the 
individual or their dependent is diagnosed with an autism 
spectrum disorder or due to the individual utilizing benefits 
in this Section.
    (f) Upon request of the reimbursing insurer, a provider of 
treatment for autism spectrum disorders shall furnish medical 
records, clinical notes, or other necessary data that 
substantiate that initial or continued medical treatment is 
medically necessary and is resulting in improved clinical 
status.  When treatment is anticipated to require continued 
services to achieve demonstrable progress, the insurer may 
request a treatment plan consisting of diagnosis, proposed 
treatment by type, frequency, anticipated duration of 
treatment, the anticipated outcomes stated as goals, and the 
frequency by which the treatment plan will be updated. 
    (g) When making a determination of medical necessity for a 
treatment modality for autism spectrum disorders, an insurer 
must make the determination in a manner that is consistent with 
the manner used to make that determination with respect to 
other diseases or illnesses covered under the policy, including 
an appeals process.  During the appeals process, any challenge 
to medical necessity must be viewed as reasonable only if the 
review includes a physician with expertise in the most current 
and effective treatment modalities for autism spectrum 
disorders.
    (h) Coverage for medically necessary early intervention 
services must be delivered by certified early intervention 
specialists, as defined in 89 Ill. Admin. Code 500 and any 
subsequent amendments thereto. 
    (h-5) If an individual has been diagnosed as having an 
autism spectrum disorder, meeting the diagnostic criteria in 
place at the time of diagnosis, and treatment is determined 
medically necessary, then that individual shall remain 
eligible for coverage under this Section even if subsequent 
changes to the diagnostic criteria are adopted by the American 
Psychiatric Association. If no changes to the diagnostic 
criteria are adopted after April 1, 2012, and before December 
31, 2014, then this subsection (h-5) shall be of no further 
force and effect.
    (i)  As used in this Section:
    "Autism spectrum disorders" means pervasive developmental 
disorders as defined in the most recent edition of the 
Diagnostic and Statistical Manual of Mental Disorders, 
including autism, Asperger's disorder, and pervasive 
developmental disorder not otherwise specified.
    "Diagnosis of autism spectrum disorders" means one or more 
tests, evaluations, or assessments to diagnose whether an 
individual has autism spectrum disorder that is prescribed, 
performed, or ordered by (A) a physician licensed to practice 
medicine in all its branches or (B) a licensed clinical 
psychologist with expertise in diagnosing autism spectrum 
disorders.
    "Medically necessary" means any care, treatment, 
intervention, service or item which will or is reasonably 
expected to do any of the following: (i) prevent the onset of 
an illness, condition, injury, disease or disability; (ii) 
reduce or ameliorate the physical, mental or developmental 
effects of an illness, condition, injury, disease or 
disability; or (iii) assist to achieve or maintain maximum 
functional activity in performing daily activities. 
    "Treatment for autism spectrum disorders" shall include 
the following care prescribed, provided, or ordered for an 
individual diagnosed with an autism spectrum disorder by (A) a 
physician licensed to practice medicine in all its branches or 
(B) a certified, registered, or licensed health care 
professional with expertise in treating effects of autism 
spectrum disorders when the care is determined to be medically 
necessary and ordered by a physician licensed to practice 
medicine in all its branches:
        (1)  Psychiatric care, meaning direct, consultative, or 
    diagnostic services provided by a licensed psychiatrist.
        (2) Psychological care, meaning direct or consultative 
    services provided by a licensed psychologist.
        (3)  Habilitative or rehabilitative care, meaning 
    professional, counseling, and guidance services and 
    treatment programs, including applied behavior analysis, 
    that are intended to develop, maintain, and restore the 
    functioning of an individual. As used in this subsection 
    (i),  "applied behavior analysis" means the design, 
    implementation, and evaluation of environmental 
    modifications using behavioral stimuli and consequences to 
    produce socially significant improvement in human 
    behavior, including the use of direct observation, 
    measurement, and functional analysis of the relations 
    between environment and behavior.
        (4)  Therapeutic care, including behavioral, speech, 
    occupational, and physical therapies that provide 
    treatment in the following areas: (i) self care and 
    feeding, (ii) pragmatic, receptive, and expressive 
    language, (iii) cognitive functioning, (iv) applied 
    behavior analysis, intervention, and modification, (v) 
    motor planning, and (vi) sensory processing.
    (j) Rulemaking authority to implement this amendatory Act 
of the 95th General Assembly, if any, is conditioned on the 
rules being adopted in accordance with all provisions of the 
Illinois Administrative Procedure Act and all rules and 
procedures of the Joint Committee on Administrative Rules; any 
purported rule not so adopted, for whatever reason, is 
unauthorized. 

(Source: P.A. 95-1005, eff. 12-12-08; 96-1000, eff. 7-2-10.)
 
    (215 ILCS 5/356z.16)
    Sec. 356z.16. Applicability of mandated benefits to 
supplemental policies. Unless specified otherwise, the 
following Sections of the Illinois Insurance Code do not apply 
to short-term travel, disability income, long-term care, 
accident only, or limited or specified disease policies: 356b, 
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, 
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 
356z.8, 356z.12, 356z.14, 356z.19, 356z.21 356z.19, 364.01,  
367.2-5, and 367e.

(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; 
96-1034, eff. 1-1-11; 97-91, eff. 1-1-12; 97-282, eff. 8-9-11; 
97-592, eff. 1-1-12; revised 10-13-11.)