Bill Amendment: IL HB5225 | 2025-2026 | 104th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: AUTISM SPECTRUM-DIAGNOSIS

Status: 2026-06-25 - Sent to the Governor [HB5225 Detail]

Download: Illinois-2025-HB5225-House_Amendment_002.html

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Rep. Natalie A. Manley

Filed: 3/24/2026

 

 

 

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AMENDMENT TO HOUSE BILL 5225
AMENDMENT NO. ______. Amend House Bill 5225 by replacing
everything after the enacting clause with the following:
"Section 5. The Illinois Insurance Code is amended by
changing Section 356z.14 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 December 12, 2008 (the effective date of Public
Act 95-1005) 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.

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(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. The Director 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.

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(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 the individual's dependent is diagnosed with an
autism spectrum disorder or due to the individual utilizing
benefits in this Section.
(e-5) An insurer may not deny or refuse to provide
otherwise covered services under a group or individual policy
of accident and health insurance or a managed care plan solely
because of the location wherein the clinically appropriate
services are provided.
(f) Upon request of the 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. Nothing in this subsection
supersedes the prohibition on prior authorization for mental
health treatment under subsection (w) of Section 370c.
(g) When making a determination of medical necessity for a

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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. Adm. 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.
(h-10) An insurer may not deny or refuse to provide
covered services, or refuse to renew, refuse to reissue, or
otherwise terminate or restrict coverage under an individual

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contract, for a person diagnosed with an autism spectrum
disorder on the basis that the individual declined an
alternative medication or covered service when the
individual's health care provider has determined that such
medication or covered service may exacerbate clinical
symptomatology and is medically contraindicated for the
individual and the individual has requested and received a
medical exception as provided for under Section 45.1 of the
Managed Care Reform and Patient Rights Act. For the purposes
of this subsection (h-10), "clinical symptomatology" means any
indication of disorder or disease when experienced by an
individual as a change from normal function, sensation, or
appearance.
(h-15) If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost
of any coverage outlined in subsection (h-10), then subsection
(h-10) is inoperative with respect to all coverage outlined in
subsection (h-10) other than that authorized under Section
1902 of the Social Security Act, 42 U.S.C. 1396a, and the State

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shall not assume any obligation for the cost of the coverage
set forth in subsection (h-10).
(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, or (C) a licensed speech-language pathologist 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

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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

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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. 103-154, eff. 6-30-23; 104-28, eff. 1-1-26;
104-417, eff. 8-15-25.)
Section 10. The Illinois Speech-Language Pathology and
Audiology Practice Act is amended by changing Section 3 and by
adding Section 8.4 as follows:
(225 ILCS 110/3) (from Ch. 111, par. 7903)
(Section scheduled to be repealed on January 1, 2028)
Sec. 3. Definitions. The following words and phrases shall
have the meaning ascribed to them in this Section unless the
context clearly indicates otherwise:
(a) "Department" means the Department of Financial and
Professional Regulation.
(b) "Secretary" means the Secretary of Financial and

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Professional Regulation.
(c) "Board" means the Board of Speech-Language Pathology
and Audiology established under Section 5 of this Act.
(d) "Speech-Language Pathologist" means a person who has
received a license pursuant to this Act and who engages in the
practice of speech-language pathology.
(e) "Audiologist" means a person who has received a
license pursuant to this Act and who engages in the practice of
audiology.
(f) "Public member" means a person who is not a health
professional. For purposes of board membership, any person
with a significant financial interest in a health service or
profession is not a public member.
(g) "The practice of audiology" is the application of
nonsurgical methods and procedures for the screening,
identification, measurement, monitoring, testing, appraisal,
prediction, interpretation, habilitation, rehabilitation, or
instruction related to audiologic or vestibular disorders,
including hearing and disorders of hearing. These procedures
are for the purpose of counseling, consulting and rendering or
offering to render services or for participating in the
planning, directing or conducting of programs that are
designed to modify communicative disorders involving speech,
language, auditory, or vestibular function related to hearing
loss. The practice of audiology may include, but shall not be
limited to, the following:

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(1) any task, procedure, act, or practice that is
necessary for the evaluation and management of audiologic,
hearing, or vestibular function, including, but not
limited to, neurophysiologic intraoperative monitoring of
the seventh or eighth cranial nerve function;
(2) training in the use of amplification devices;
(3) the evaluation, fitting, dispensing, or servicing
of hearing instruments and auditory prosthetic devices,
such as cochlear implants, auditory osseointegrated
devices, and brainstem implants;
(4) cerumen removal;
(5) performing basic speech and language screening
tests and procedures consistent with audiology training;
and
(6) performing basic health screenings in accordance
with Section 8.3 of this Act.
(h) "The practice of speech-language pathology" is the
application of nonmedical methods and procedures for the
identification, measurement, testing, appraisal, prediction,
habilitation, rehabilitation, and modification related to
communication development, and disorders or disabilities of
speech, language, voice, swallowing, and other speech,
language and voice related disorders. These procedures are for
the purpose of counseling, consulting and rendering or
offering to render services, or for participating in the
planning, directing or conducting of programs that are

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designed to modify communicative disorders and conditions in
individuals or groups of individuals involving speech,
language, voice and swallowing function.
"The practice of speech-language pathology" shall include,
but shall not be limited to, the following:
(1) hearing screening tests and aural rehabilitation
procedures consistent with speech-language pathology
training;
(2) tasks, procedures, acts or practices that are
necessary for the evaluation of, and training in the use
of, augmentative communication systems, communication
variation, cognitive rehabilitation, non-spoken language
production and comprehension;
(3) the use of rigid or flexible laryngoscopes for the
sole purpose of observing and obtaining images of the
pharynx and larynx in accordance with Section 9.3 of this
Act; and
(4) performing basic health screenings in accordance
with Section 8.3 of this Act; and .
(5) diagnosing autism spectrum disorders in accordance
with Section 8.4 of this Act.
(i) "Speech-language pathology assistant" means a person
who has received a license pursuant to this Act to assist a
speech-language pathologist in the manner provided in this
Act.
(j) "Physician" means a physician licensed to practice

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medicine in all its branches under the Medical Practice Act of
1987.
(k) "Email address of record" means the designated email
address recorded by the Department in the applicant's
application file or the licensee's license file, as maintained
by the Department's licensure maintenance unit.
(l) "Address of record" means the designated address
recorded by the Department in the applicant's or licensee's
application file or license file as maintained by the
Department's licensure maintenance unit.
(m) "Neurophysiologic intraoperative monitoring" means the
process of continual testing and interpretation of test
results using electrodiagnostic modalities to monitor the
seventh and eighth cranial nerve function during a surgical
procedure. Neurophysiologic intraoperative monitoring does not
include testing and interpretation of test results using
electrodiagnostic modalities to monitor the spinal cord,
peripheral nerves (other than the seventh and eighth cranial
nerve), cerebral hemispheres, or brainstem. Neurophysiologic
intraoperative monitoring may be performed by an audiologist
only if authorized by the physician performing the surgical
procedure.
(Source: P.A. 100-530, eff. 1-1-18.)
(225 ILCS 110/8.4 new)
Sec. 8.4. Diagnosing autism spectrum disorders. A

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speech-language pathologist may diagnose autism spectrum
disorders if:
(1) the child is under 3 years of age and has no known
co-occurring medical conditions, such as seizures,
gastrointestinal problems, or sleep disorders;
(2) the speech-language pathologist is trained in
autism diagnostic evaluation methods as part of an
approved Illinois Early Intervention training; and
(3) the diagnosis occurs as part of the Illinois Early
Intervention Program.
If a diagnosis requires a plan of care that includes
elements that are outside the scope of practice of a
speech-language pathologist (such as seizures,
gastrointestinal problems, or sleep disorders), the
speech-language pathologist must refer the patient to the
appropriate medical personnel for further evaluation or
management.
Section 15. The Illinois Public Aid Code is amended by
changing Section 5-30.11 as follows:
(305 ILCS 5/5-30.11)
Sec. 5-30.11. Treatment of autism spectrum disorder.
Treatment of autism spectrum disorder through applied behavior
analysis shall be covered under the medical assistance program
under this Article for children with a diagnosis of autism

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spectrum disorder when (1) ordered by a physician licensed to
practice medicine in all its branches, or a psychologist
licensed by the Department of Financial and Professional
Regulation, or a speech-language pathologist licensed by the
Department of Financial and Professional Regulation and (2)
evaluated by a behavior analyst as recognized by the
Department or licensed by the Department of Financial and
Professional Regulation to practice applied behavior analysis
in this State. Such coverage may be limited to age ranges based
on evidence-based best practices. Appropriate State plan
amendments as well as rules regarding provision of services
and providers will be submitted by September 1, 2019. Pursuant
to the flexibilities allowed by the federal Centers for
Medicare and Medicaid Services to Illinois under the Medical
Assistance Program, the Department shall enroll and reimburse
qualified staff to perform applied behavior analysis services
in advance of Illinois licensure activities performed by the
Department of Financial and Professional Regulation. These
services shall be covered if they are provided in a home or
community setting or in an office-based setting. The
Department may conduct annual on-site reviews of the services
authorized under this Section. Provider enrollment shall occur
no later than September 1, 2023.
(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22;
103-102, eff. 7-1-23.)

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Section 20. The Department of Early Childhood Act is
amended by adding Section 10-125 and 10-130 as follows:
(325 ILCS 3/10-125 new)
Sec. 10-125. Autism spectrum disorders. The Department
shall adopt rules consistent with the purposes of this
amendatory Act of the 104th General Assembly authorizing
speech-language pathologists licensed by the Department of
Financial and Professional Regulation to diagnose autism
spectrum disorders under the Illinois Early Intervention
Program. When developing rules, the Department shall consult
with relevant stakeholders, including developmental and
behavioral pediatricians, a statewide association representing
pediatricians, a statewide association representing child and
adolescent psychiatrists, a statewide association representing
psychologists, and a statewide association representing
speech-language pathologists.
Section 99. Effective date. This Act takes effect January
1, 2028.".