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HB5225 Enrolled LRB104 20453 AAS 33918 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.14 as follows:
6 (215 ILCS 5/356z.14)
7 Sec. 356z.14. Autism spectrum disorders.
8 (a) A group or individual policy of accident and health
9 insurance or managed care plan amended, delivered, issued, or
10 renewed after December 12, 2008 (the effective date of Public
11 Act 95-1005) must provide individuals under 21 years of age
12 coverage for the diagnosis of autism spectrum disorders and
13 for the treatment of autism spectrum disorders to the extent
14 that the diagnosis and treatment of autism spectrum disorders
15 are not already covered by the policy of accident and health
16 insurance or managed care plan.
17 (b) Coverage provided under this Section shall be subject
18 to a maximum benefit of $36,000 per year but shall not be
19 subject to any limits on the number of visits to a service
20 provider. The Director of Insurance shall, on an annual basis,
21 adjust the maximum benefit for inflation using the Medical
22 Care Component of the United States Department of Labor
23 Consumer Price Index for All Urban Consumers. Payments made by
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1 an insurer on behalf of a covered individual for any care,
2 treatment, intervention, service, or item, the provision of
3 which was for the treatment of a health condition not
4 diagnosed as an autism spectrum disorder, shall not be applied
5 toward any maximum benefit established under this subsection.
6 (c) Coverage under this Section shall be subject to
7 copayment, deductible, and coinsurance provisions of a policy
8 of accident and health insurance or managed care plan to the
9 extent that other medical services covered by the policy of
10 accident and health insurance or managed care plan are subject
11 to these provisions.
12 (d) This Section shall not be construed as limiting
13 benefits that are otherwise available to an individual under a
14 policy of accident and health insurance or managed care plan
15 and benefits provided under this Section may not be subject to
16 dollar limits, deductibles, copayments, or coinsurance
17 provisions that are less favorable to the insured than the
18 dollar limits, deductibles, or coinsurance provisions that
19 apply to physical illness generally.
20 (e) An insurer may not deny or refuse to provide otherwise
21 covered services, or refuse to renew, refuse to reissue, or
22 otherwise terminate or restrict coverage under an individual
23 contract to provide services to an individual because the
24 individual or the individual's dependent is diagnosed with an
25 autism spectrum disorder or due to the individual utilizing
26 benefits in this Section.
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1 (e-5) An insurer may not deny or refuse to provide
2 otherwise covered services under a group or individual policy
3 of accident and health insurance or a managed care plan solely
4 because of the location wherein the clinically appropriate
5 services are provided.
6 (f) Upon request of the insurer, a provider of treatment
7 for autism spectrum disorders shall furnish medical records,
8 clinical notes, or other necessary data that substantiate that
9 initial or continued medical treatment is medically necessary
10 and is resulting in improved clinical status. When treatment
11 is anticipated to require continued services to achieve
12 demonstrable progress, the insurer may request a treatment
13 plan consisting of diagnosis, proposed treatment by type,
14 frequency, anticipated duration of treatment, the anticipated
15 outcomes stated as goals, and the frequency by which the
16 treatment plan will be updated. Nothing in this subsection
17 supersedes the prohibition on prior authorization for mental
18 health treatment under subsection (w) of Section 370c.
19 (g) When making a determination of medical necessity for a
20 treatment modality for autism spectrum disorders, an insurer
21 must make the determination in a manner that is consistent
22 with the manner used to make that determination with respect
23 to other diseases or illnesses covered under the policy,
24 including an appeals process. During the appeals process, any
25 challenge to medical necessity must be viewed as reasonable
26 only if the review includes a physician with expertise in the
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1 most current and effective treatment modalities for autism
2 spectrum disorders.
3 (h) Coverage for medically necessary early intervention
4 services must be delivered by certified early intervention
5 specialists, as defined in 89 Ill. Adm. Code 500 and any
6 subsequent amendments thereto.
7 (h-5) If an individual has been diagnosed as having an
8 autism spectrum disorder, meeting the diagnostic criteria in
9 place at the time of diagnosis, and treatment is determined
10 medically necessary, then that individual shall remain
11 eligible for coverage under this Section even if subsequent
12 changes to the diagnostic criteria are adopted by the American
13 Psychiatric Association. If no changes to the diagnostic
14 criteria are adopted after April 1, 2012, and before December
15 31, 2014, then this subsection (h-5) shall be of no further
16 force and effect.
17 (h-10) An insurer may not deny or refuse to provide
18 covered services, or refuse to renew, refuse to reissue, or
19 otherwise terminate or restrict coverage under an individual
20 contract, for a person diagnosed with an autism spectrum
21 disorder on the basis that the individual declined an
22 alternative medication or covered service when the
23 individual's health care provider has determined that such
24 medication or covered service may exacerbate clinical
25 symptomatology and is medically contraindicated for the
26 individual and the individual has requested and received a
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1 medical exception as provided for under Section 45.1 of the
2 Managed Care Reform and Patient Rights Act. For the purposes
3 of this subsection (h-10), "clinical symptomatology" means any
4 indication of disorder or disease when experienced by an
5 individual as a change from normal function, sensation, or
6 appearance.
7 (h-15) If, at any time, the Secretary of the United States
8 Department of Health and Human Services, or its successor
9 agency, promulgates rules or regulations to be published in
10 the Federal Register or publishes a comment in the Federal
11 Register or issues an opinion, guidance, or other action that
12 would require the State, pursuant to any provision of the
13 Patient Protection and Affordable Care Act (Public Law
14 111-148), including, but not limited to, 42 U.S.C.
15 18031(d)(3)(B) or any successor provision, to defray the cost
16 of any coverage outlined in subsection (h-10), then subsection
17 (h-10) is inoperative with respect to all coverage outlined in
18 subsection (h-10) other than that authorized under Section
19 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State
20 shall not assume any obligation for the cost of the coverage
21 set forth in subsection (h-10).
22 (i) As used in this Section:
23 "Autism spectrum disorders" means pervasive developmental
24 disorders as defined in the most recent edition of the
25 Diagnostic and Statistical Manual of Mental Disorders,
26 including autism, Asperger's disorder, and pervasive
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1 developmental disorder not otherwise specified.
2 "Diagnosis of autism spectrum disorders" means one or more
3 tests, evaluations, or assessments to diagnose whether an
4 individual has autism spectrum disorder that are is
5 prescribed, performed, or ordered by (A) a physician licensed
6 to practice medicine in all its branches, or (B) a licensed
7 clinical psychologist with expertise in diagnosing autism
8 spectrum disorders, or (C) a licensed speech-language
9 pathologist with expertise in diagnosing autism spectrum
10 disorders in children under age 3.
11 "Medically necessary" means any care, treatment,
12 intervention, service, or item which will or is reasonably
13 expected to do any of the following: (i) prevent the onset of
14 an illness, condition, injury, disease, or disability; (ii)
15 reduce or ameliorate the physical, mental, or developmental
16 effects of an illness, condition, injury, disease, or
17 disability; or (iii) assist to achieve or maintain maximum
18 functional activity in performing daily activities.
19 "Treatment for autism spectrum disorders" shall include
20 the following care prescribed, provided, or ordered for an
21 individual diagnosed with an autism spectrum disorder by (A) a
22 physician licensed to practice medicine in all its branches or
23 (B) a certified, registered, or licensed health care
24 professional with expertise in treating effects of autism
25 spectrum disorders when the care is determined to be medically
26 necessary and ordered by a physician licensed to practice
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1 medicine in all its branches:
2 (1) Psychiatric care, meaning direct, consultative, or
3 diagnostic services provided by a licensed psychiatrist.
4 (2) Psychological care, meaning direct or consultative
5 services provided by a licensed psychologist.
6 (3) Habilitative or rehabilitative care, meaning
7 professional, counseling, and guidance services and
8 treatment programs, including applied behavior analysis,
9 that are intended to develop, maintain, and restore the
10 functioning of an individual. As used in this subsection
11 (i), "applied behavior analysis" means the design,
12 implementation, and evaluation of environmental
13 modifications using behavioral stimuli and consequences to
14 produce socially significant improvement in human
15 behavior, including the use of direct observation,
16 measurement, and functional analysis of the relations
17 between environment and behavior.
18 (4) Therapeutic care, including behavioral, speech,
19 occupational, and physical therapies that provide
20 treatment in the following areas: (i) self care and
21 feeding, (ii) pragmatic, receptive, and expressive
22 language, (iii) cognitive functioning, (iv) applied
23 behavior analysis, intervention, and modification, (v)
24 motor planning, and (vi) sensory processing.
25 (j) Rulemaking authority to implement this amendatory Act
26 of the 95th General Assembly, if any, is conditioned on the
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1 rules being adopted in accordance with all provisions of the
2 Illinois Administrative Procedure Act and all rules and
3 procedures of the Joint Committee on Administrative Rules; any
4 purported rule not so adopted, for whatever reason, is
5 unauthorized.
6 (Source: P.A. 103-154, eff. 6-30-23; 104-28, eff. 1-1-26;
7 104-417, eff. 8-15-25.)
8 Section 10. The Illinois Speech-Language Pathology and
9 Audiology Practice Act is amended by changing Section 3 and by
10 adding Section 8.4 as follows:
11 (225 ILCS 110/3) (from Ch. 111, par. 7903)
12 (Section scheduled to be repealed on January 1, 2028)
13 Sec. 3. Definitions. The following words and phrases shall
14 have the meaning ascribed to them in this Section unless the
15 context clearly indicates otherwise:
16 (a) "Department" means the Department of Financial and
17 Professional Regulation.
18 (b) "Secretary" means the Secretary of Financial and
19 Professional Regulation.
20 (c) "Board" means the Board of Speech-Language Pathology
21 and Audiology established under Section 5 of this Act.
22 (d) "Speech-Language Pathologist" means a person who has
23 received a license pursuant to this Act and who engages in the
24 practice of speech-language pathology.
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1 (e) "Audiologist" means a person who has received a
2 license pursuant to this Act and who engages in the practice of
3 audiology.
4 (f) "Public member" means a person who is not a health
5 professional. For purposes of board membership, any person
6 with a significant financial interest in a health service or
7 profession is not a public member.
8 (g) "The practice of audiology" is the application of
9 nonsurgical methods and procedures for the screening,
10 identification, measurement, monitoring, testing, appraisal,
11 prediction, interpretation, habilitation, rehabilitation, or
12 instruction related to audiologic or vestibular disorders,
13 including hearing and disorders of hearing. These procedures
14 are for the purpose of counseling, consulting and rendering or
15 offering to render services or for participating in the
16 planning, directing or conducting of programs that are
17 designed to modify communicative disorders involving speech,
18 language, auditory, or vestibular function related to hearing
19 loss. The practice of audiology may include, but shall not be
20 limited to, the following:
21 (1) any task, procedure, act, or practice that is
22 necessary for the evaluation and management of audiologic,
23 hearing, or vestibular function, including, but not
24 limited to, neurophysiologic intraoperative monitoring of
25 the seventh or eighth cranial nerve function;
26 (2) training in the use of amplification devices;
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1 (3) the evaluation, fitting, dispensing, or servicing
2 of hearing instruments and auditory prosthetic devices,
3 such as cochlear implants, auditory osseointegrated
4 devices, and brainstem implants;
5 (4) cerumen removal;
6 (5) performing basic speech and language screening
7 tests and procedures consistent with audiology training;
8 and
9 (6) performing basic health screenings in accordance
10 with Section 8.3 of this Act.
11 (h) "The practice of speech-language pathology" is the
12 application of nonmedical methods and procedures for the
13 identification, measurement, testing, appraisal, prediction,
14 habilitation, rehabilitation, and modification related to
15 communication development, and disorders or disabilities of
16 speech, language, voice, swallowing, and other speech,
17 language and voice related disorders. These procedures are for
18 the purpose of counseling, consulting and rendering or
19 offering to render services, or for participating in the
20 planning, directing or conducting of programs that are
21 designed to modify communicative disorders and conditions in
22 individuals or groups of individuals involving speech,
23 language, voice and swallowing function.
24 "The practice of speech-language pathology" shall include,
25 but shall not be limited to, the following:
26 (1) hearing screening tests and aural rehabilitation
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1 procedures consistent with speech-language pathology
2 training;
3 (2) tasks, procedures, acts or practices that are
4 necessary for the evaluation of, and training in the use
5 of, augmentative communication systems, communication
6 variation, cognitive rehabilitation, non-spoken language
7 production and comprehension;
8 (3) the use of rigid or flexible laryngoscopes for the
9 sole purpose of observing and obtaining images of the
10 pharynx and larynx in accordance with Section 9.3 of this
11 Act; and
12 (4) performing basic health screenings in accordance
13 with Section 8.3 of this Act; and.
14 (5) diagnosing autism spectrum disorders in accordance
15 with Section 8.4 of this Act.
16 (i) "Speech-language pathology assistant" means a person
17 who has received a license pursuant to this Act to assist a
18 speech-language pathologist in the manner provided in this
19 Act.
20 (j) "Physician" means a physician licensed to practice
21 medicine in all its branches under the Medical Practice Act of
22 1987.
23 (k) "Email address of record" means the designated email
24 address recorded by the Department in the applicant's
25 application file or the licensee's license file, as maintained
26 by the Department's licensure maintenance unit.
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1 (l) "Address of record" means the designated address
2 recorded by the Department in the applicant's or licensee's
3 application file or license file as maintained by the
4 Department's licensure maintenance unit.
5 (m) "Neurophysiologic intraoperative monitoring" means the
6 process of continual testing and interpretation of test
7 results using electrodiagnostic modalities to monitor the
8 seventh and eighth cranial nerve function during a surgical
9 procedure. Neurophysiologic intraoperative monitoring does not
10 include testing and interpretation of test results using
11 electrodiagnostic modalities to monitor the spinal cord,
12 peripheral nerves (other than the seventh and eighth cranial
13 nerve), cerebral hemispheres, or brainstem. Neurophysiologic
14 intraoperative monitoring may be performed by an audiologist
15 only if authorized by the physician performing the surgical
16 procedure.
17 (Source: P.A. 100-530, eff. 1-1-18.)
18 (225 ILCS 110/8.4 new)
19 Sec. 8.4. Diagnosing autism spectrum disorders. A
20 speech-language pathologist may diagnose autism spectrum
21 disorders if:
22 (1) the child is under 3 years of age and has no known
23 co-occurring medical conditions, such as seizures,
24 gastrointestinal problems, or sleep disorders;
25 (2) the speech-language pathologist has completed
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1 training in age-appropriate autism diagnostic evaluation
2 methods provided by an approved continuing education
3 sponsor;
4 (3) the speech-language pathologist has, upon renewal
5 of the speech-language pathologist's license, certified to
6 the Department that at least 5 of the speech-language
7 pathologist's required continuing education hours were in
8 age-appropriate autism diagnostic evaluation methods
9 provided by an approved continuing education sponsor; and
10 (4) the diagnosis occurs as part of the Illinois Early
11 Intervention Program.
12 The speech-language pathologist must refer the child to
13 the appropriate medical personnel for further evaluation or
14 management for services outside the scope of practice of a
15 speech-language pathologist.
16 Section 15. The Illinois Public Aid Code is amended by
17 changing Section 5-30.11 as follows:
18 (305 ILCS 5/5-30.11)
19 Sec. 5-30.11. Treatment of autism spectrum disorder.
20 Treatment of autism spectrum disorder through applied behavior
21 analysis shall be covered under the medical assistance program
22 under this Article for children with a diagnosis of autism
23 spectrum disorder when (1) ordered by a physician licensed to
24 practice medicine in all its branches, or a psychologist
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1 licensed by the Department of Financial and Professional
2 Regulation, or a speech-language pathologist licensed by the
3 Department of Financial and Professional Regulation, so long
4 as the diagnosis by the speech-language pathologist occurs as
5 part of the Illinois Early Intervention Program, and (2)
6 evaluated by a behavior analyst as recognized by the
7 Department or licensed by the Department of Financial and
8 Professional Regulation to practice applied behavior analysis
9 in this State. Such coverage may be limited to age ranges based
10 on evidence-based best practices. Appropriate State plan
11 amendments as well as rules regarding provision of services
12 and providers will be submitted by September 1, 2019. Pursuant
13 to the flexibilities allowed by the federal Centers for
14 Medicare and Medicaid Services to Illinois under the Medical
15 Assistance Program, the Department shall enroll and reimburse
16 qualified staff to perform applied behavior analysis services
17 in advance of Illinois licensure activities performed by the
18 Department of Financial and Professional Regulation. These
19 services shall be covered if they are provided in a home or
20 community setting or in an office-based setting. The
21 Department may conduct annual on-site reviews of the services
22 authorized under this Section. Provider enrollment shall occur
23 no later than September 1, 2023.
24 (Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22;
25 103-102, eff. 7-1-23.)
26 Section 99. Effective date. This Act takes effect January
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1 1, 2028.Every fact on this page links to its source, starting with the official bill record.