Illinois Children with Autism Benefit from State Health Insurance Law

August 9, 2010

With the passage of Public Act 95-1005, the state of Illinois joined a host of other states in mandating coverage for the diagnosis and treatment of autism spectrum disorders in children under the age of 21. In effect since December 2009, the law applies to all individual and group health insurance policies as well as insurance for public employees and HMO contracts issued, delivered, amended or renewed after December 12, 2008. Individuals covered by policies issued prior to that date may have to wait for the renewal or anniversary date to include autism in the policy.

Some types of insurance exempt from providing coverage

Types of insurance that are not covered by the autism law include plans for self-insured, non-public employers; trusts and policies issued outside of Illinois; and plans provided for union members. Out-of-state HMOs are exceptions to this if a member is a resident of Illinois and the plan has a provider within the state.

Who Can Benefit from the Coverage?

Any child under the age of 21 who is covered by an individual, group, HMO or public employee policy that comes under the mandate of the law can benefit from coverage that includes diagnosis and treatment for autism.

Treatments Covered by the Autism Health Insurance Law

With an annual benefit of $36,000, insurance companies are required to cover the diagnosis along with the following treatments for autism spectrum disorders:

  • Therapeutic care such as speech, occupational, behavioral and physical therapies
  • Psychological care given by a licensed psychologist
  • Psychiatric care given by a licensed psychiatrist
  • Habilitative and rehabilitative care

All medically necessary treatments prescribed by a physician are covered by medical insurance with no bias allowed toward the type of provider and no caps put on the number of visits to either physicians or other service providers.

Can Coverage be Denied for a Pre-existing Condition?

Any medical condition that has been diagnosed, treated or recommended for treatment before a patient enrolls in an insurance plan can be considered as pre-existing condition. The condition can be justified for any reason other than "race, color, religion or national origin."

Illinois law allows insurance companies to deny coverage for pre-existing conditions for up to two years depending upon specific policies and circumstances. However, HMO plans are not allowed to exclude coverage, but can limit it for up to 12 months through deductibles and co-payments. The Health Insurance Portability and Accountability Act (HIPAA) provides a variety of protections for those with pre-existing conditions who are insured through their employers.

Federal Legislation

According to the U.S. Patient Protection and Affordable Care Act, in Illinois children to the age of 19 are guaranteed autism benefits effective September 23, 2010. Young adults 19 to 21 who have coverage have access to benefits, but if the family seeks coverage at that age, benefits could be denied.

Young Adult Dependent Coverage

Following the passage of Public Act 95-0958, all individual and group health insurance policies along with HMO contracts that cover dependents must extend coverage to age 26 and up to age 30 for military. However, the law does not extend autism benefits beyond 21 and it does not apply to contracts and policies that are also exempt from Public Act 95-1005, as listed above.

For more specific information visit http://insurance.illinois.gov or call (877) 527-9431.

Jeanne Lauf Walpole

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