AUTISM SPECTRUM-DIAGNOSIS

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HB5225 - 104th General Assembly

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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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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.

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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.

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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;

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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.

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
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

HB5225 Enrolled
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LRB104 20453 AAS 33918 b
1
1, 2028.

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