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(6) According to the Centers for Disease Control, |
autism rates increased 78% between 2002 and 2008. The most |
recent estimate is roughly 30% higher than the estimate for |
2008 (one in 88), 60% higher than the estimate for 2006 |
(one in 110), and 120% higher than the estimates for 2000 |
and 2002 (one in 150). |
(7) While autism spectrum disorders have primarily |
been diagnosed in measuring deficits in the areas of |
communication, socialization, and behavior, recent |
clinical and scientific investigations have determined |
that co-occurring pathophysiological conditions may occur |
more commonly in persons also diagnosed with autism.
These |
pathologies include, but are not limited to, allergies, |
autoimmune conditions, gastrointestinal diseases, immune |
dysregulation, metabolic disturbances, mitochondrial |
abnormalities, oxidative stress, neuroinflammation, and |
seizure disorders. |
(8) Scientific inquiry is providing evidence of |
biological markers, including, but not limited to, single |
nucleotide polymorphisms, indications of cellular |
inflammation, increased cellular oxidation and damage, and |
abnormal DNA methylation, that may be clinically |
significant in the provision of appropriate medical care |
for persons also diagnosed with an autism spectrum |
disorder. |
Therefore, it is the intention of the General Assembly to |
|
promote a greater awareness and the detection, diagnosis, and |
treatment of underlying and co-occurring medical conditions |
that occur more commonly in persons with autism to further |
awareness, scientific understanding, and health outcomes for |
persons living with autism.
|
Section 10. Definitions. In this Act: |
"Autism spectrum disorder" means a neurobiological |
disorder, including autism, regressive autism, Asperger |
Syndrome, and pervasive developmental disorders not otherwise |
specified. |
"Clinical symptomatology" means any indication of disorder |
or disease when experienced by an individual as a change from |
normal function, sensation, or appearance. |
"Co-occurring or otherwise diagnosed medical condition" |
means a simultaneous illness, condition, injury, disease, |
pathology, or disability that is not primarily diagnosed as an |
autism spectrum disorder. |
"Department" means the Department of Financial and |
Professional Regulation. |
"Pathophysiological" means the functional alterations in |
the body related to a disease or syndrome. |
"Provider" means any provider of healthcare services in |
this State.
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Section 15. Study and education. Public partnerships and |
|
private partnerships supporting the discovery of biomarkers |
and their implications in pathophysiological conditions shall |
be encouraged and information derived from such discoveries |
shall be disseminated to providers and made available to the |
general public through research initiatives that may be |
promoted by universities, medical clinics, health care |
providers, consortiums, State agencies, private organizations, |
public organizations, and any party that may contribute to the |
scientific understanding of medical conditions associated or |
occurring more often in persons also diagnosed with an autism |
spectrum disorder than in the general population. |
Universities, private organizations, public organizations, |
and associations are encouraged to develop for providers who |
treat persons with autism spectrum disorders continuing |
education courses which address training in evaluation, |
diagnosis, and treatments for co-occurring and otherwise |
diagnosed pathophysiological conditions in autism spectrum |
disorders to promote and align standard of care practices to |
reflect emerging clinical findings and promising practices |
derived from improved patient outcomes.
|
Section 20. Treatment or service of persons with an autism |
spectrum disorder. Providers are strongly encouraged to |
evaluate persons diagnosed with an autism spectrum disorder for |
co-occurring or otherwise diagnosed medical conditions when |
clinical symptomatology is present or suspected and prescribe |
|
appropriate treatments or services in alignment with care |
practices for the condition, illness, injury, disease, or |
disability. Providers may consider, without limitation, |
whether or not a medication or any ingredient, allergen, |
potential toxicant, or artificial agent may exacerbate |
clinical symptomatology of autism spectrum disorder or a |
related or co-occurring or otherwise diagnosed medical |
condition and, if so, may consider adopting measures that would |
result in the reduction or elimination of risk to the patient.
|
Section 25. Complaints. Any person with an autism spectrum |
disorder, or the person's parent or legal guardian on his or |
her behalf, who believes they have not received an appropriate |
medical assessment, evaluation, diagnosis, service or |
treatment from a provider because he or she is also diagnosed |
with an autism spectrum disorder may report the incident to the |
Department.
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Section 30. Right to seek new care. A person with an autism |
spectrum disorder, or the person's parent or legal guardian on |
his or her behalf, retains the right to seek further medical |
opinions or care from other providers. |
A parent or legal guardian shall not be threatened with |
loss of parental or legal guardianship rights for a person with |
autism spectrum disorder for pursuing additional medical |
expertise, especially in the case of trying to ascertain |
|
appropriate identification and diagnosis of underlying or |
co-occurring medical conditions that may or may not be |
exacerbating symptoms primarily associated with an autism |
spectrum disorder. This Section does not abrogate or restrict |
any responsibilities set forth under the Abused and Neglected |
Child Reporting Act. |
Any person diagnosed as having an autism spectrum disorder |
or his or her parent or legal guardian shall not be denied the |
right to pursue appropriate and available medical |
interventions or treatments that may help to ameliorate or |
improve the symptoms primarily associated with an autism |
spectrum disorder or co-occurring or otherwise diagnosed |
medical condition. |
Any person diagnosed as having an autism spectrum disorder |
or his or her parent or legal guardian shall not be denied the |
right to decline a medical treatment or intervention.
|
Section 35. Repeal. In order to consider the most |
innovative medical study and research involving autism and |
co-occurring medical conditions, this Act is repealed 5 years |
after the effective date of this Act.
|
Section 90. The Illinois Insurance Code is amended by |
changing Section 356z.14 and by adding Section 356z.24 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. |
(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 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 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. |
"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. 96-1000, eff. 7-2-10; 97-972, eff. 1-1-13.)
|
(215 ILCS 5/356z.24 new) |
Sec. 356z.24. Immune gamma globulin therapy. |
(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 |
99th General Assembly may not allow for the delay, |
discontinuation, or interruption of immune gamma globulin |
therapy for persons who are diagnosed with a primary |
immunodeficiency when prescribed as medically necessary by a |
physician licensed to practice medicine in all of its branches |
|
and if provided as a covered benefit under the plan. Nothing in |
this Section shall prevent an insurer from applying appropriate |
utilization review standards to the ongoing coverage of immune |
gamma globulin therapy for persons diagnosed with a primary |
immunodeficiency by a physician licensed to practice medicine |
in all of its branches. |
(b) Upon diagnosis of primary immunodeficiency by the |
prescribing physician, determination of an initial |
authorization for immune gamma globulin therapy shall be no |
less than 3 months. Reauthorization for immune gamma globulin |
therapy for patients with a primary immunodeficiency diagnosis |
may occur every 6 months thereafter. For patients with a |
diagnosis of primary immunodeficiency who have been receiving |
immune gamma globulin therapy for at least 2 years with |
sustained beneficial response based on the treatment notes or |
clinical narrative detailing progress to date, reauthorization |
shall be no less than 12 months unless a more frequent duration |
has been indicated by the prescribing physician. |
(c) 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 subsections (a) and (b), then subsections (a) and |
(b) are inoperative with respect to all coverage outlined in |
subsections (a) and (b) other than that authorized under |
Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and |
the State shall not assume any obligation for the cost of the |
coverage set forth in subsections (a) and (b).
|
