Autism News Networkribbon

Illinois Senate Bill 1900 update.

New law  promises insurance coverage for Illinois children with autism

December 12, 2008: Law signed after passing as part of Senate Bill 934.

This bill has passed the Illinois General Assembly.  An amendment which would give rule-making authority control to the legislature instead of the governor held up the law as a dispute between the legislature and the governor.  footnote

Contents of Senate Bill 1900:
  1. A policy must contain coverage for autism for children under the age of 21
  2. This new coverage is capped at $36,000, with no limit to number of visits
  3. Parity of copayments with other types of benefits
  4. Other coverage shall not be limited
  5. Policies cannot refused because of an autism diagnosis
  6. Insurer can require proof of medical necessity
  7. Insurer must determine coverage based on current medical knowledge
  8. Certified medical  interventions specialists
  9. Definitions: Autism Spectrum Disorders, Medically Necessary, and Treatments
  10. (late amendment): Rule-making oversight
 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  co-payment, 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 the early intervention operational  standards by the Department of Human Services and in accordance  with applicable certification requirements.

     (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 a diagnosis  of an individual with an autism spectrum disorder 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, including diagnostic services.         
  • (2) Psychological assessments and treatments.         
  • (3) Rehabilitative treatments.         
  • (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.

( footnote: Controverted Amendment, which was not included)

   (j) Notwithstanding any other rulemaking authority that may exist, neither the Governor nor any agency or agency head    under the jurisdiction of the Governor has any authority to    make or promulgate rules to implement or enforce the provisions    of this amendatory Act of the 95th General Assembly. If,    however, the Governor believes that rules are necessary to    implement or enforce the provisions of this amendatory Act of    the 95th General Assembly, the Governor may suggest rules to    the General Assembly by filing them with the Clerk of the House    and the Secretary of the Senate and by requesting that the    General Assembly authorize such rulemaking by law, enact those    suggested rules into law, or take any other appropriate action    in the General Assembly's discretion. Nothing contained in this    amendatory Act of the 95th General Assembly shall be    interpreted to grant rulemaking authority under any other Illinois statute where such authority is not otherwise    explicitly given. For the purposes of this amendatory Act of    the 95th General Assembly, "rules" is given the meaning    contained in Section 1-70 of the Illinois Administrative    Procedure Act, and "agency" and "agency head" are given the    meanings contained in Sections 1-20 and 1-25 of the Illinois    Administrative Procedure Act to the extent that such    definitions apply to agencies or agency heads under the    jurisdiction of the Governor.".

back to AutismNews Insurance page

Page sponsor

AutismNews home
 top of page