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Insurance Coverage for Autism - State of IL


Beginning December 12, 2008, all individual and group health insurance policies and HMO contracts must abide by the provisions of Public Act 95-1005 (215 ILCS 356z.14).
This new Illinois law provides coverage for the diagnosis and treatment of autism spectrum disorders for children under 21, establishing an annual benefit of $36,000 for services provided pursuant to this Act.

The law became effective December 12, 2008. Any policy issued, delivered, amended or renewed after this date must include autism coverage required by the law.
If an employee is covered by a group health insurance policy (i.e., through your employer) issued before December 12, 2008, an employee may have to wait until the date that the policy is amended or renewed before your child is eligible for autism coverage under this law.


All individual and group health insurance policies and HMO contracts (and voluntary health service organization contracts) must abide by the new law.
Health coverage provided to state, county, and municipal employees (and employees subject to the Schools Code (105 ILCS 5/1-1 et seq.)) must also provide the autism benefits.

The Autism Law Does Not Apply to:
Self-insured, non-public employers.
Self-insured health and welfare plans, such as union plans.


Who is Covered?
Children under the age of 21 who have health coverage through an individual or group policy, will receive coverage for the diagnosis and treatment of autism spectrum disorders


What is Covered?
The new law requires coverage for the diagnosis of autism spectrum disorders.
For individuals diagnosed with an autism spectrum disorder, the new law also requires coverage for the following treatment:
▪Psychiatric care;
▪Psychological care;
▪Habilitative or rehabilitative care (counseling and treatment programs intended to develop,
maintain, and restore the functioning of an individual); and
▪Therapeutic care, including behavioral, speech, occupational, and physical therapies addressing the following areas:
▪Self-care and feeding
▪Pragmatic, receptive, and expressive language
▪Cognitive functioning
▪Applied behavioral analysis, intervention, and modification
▪Motor planning
▪Sensory processing

Insurance companies may not impose dollar limits, deductibles or copayments for the diagnosis or treatment of autism which differ from the dollar limits, deductibles or copayments established for physical illness.
All services covered by this new law must be prescribed by a physician.
However, some of the services may be delivered by certified or licensed professionals who are not physicians (e.g., speech therapists, physical therapists, and occupational therapists).
Insurance companies are required to cover medically necessary care provided by these professionals.


What are the Limits of Coverage Under the New Law?
This law requires insurance companies to provide coverage for the diagnosis and treatment of autism up to an annual limit of $36,000.
An insurance company may provide coverage beyond this limit, but is not required to do so by this law.
▪Insurance companies are prohibited from limiting the number of visits to a physician or other service provider.
▪Treatments for conditions not diagnosed as autism will not apply to the $36,000 annual limit.


Can Insurers Refuse to Cover Individuals with Autism?
Group health insurance policies are not allowed to refuse enrollment based on health status.

Is Autism Subject To Pre-Existing Condition Limitations?
Yes. Illinois law allows insurance companies to exclude coverage for pre-existing conditions, including autism, for up to 2 years.
Specific exclusion periods vary based on individual circumstances, including the type of policy and an individual's history of health insurance coverage.



Can Insurers Deny Claims Based on Medical Necessity?
Like coverage for other conditions, coverage for the treatment of autism is subject to insurance company determinations of medical necessity.
An insurance company may deny coverage for a certain treatment if the treatment is not medically necessary or does not result in improved clinical status.
A treatment must be considered medically necessary if it is reasonably expected to:
▪ Prevent the onset of an illness, condition, injury, disease or disability;
▪Reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease or disability; or
▪Help an individual achieve or maintain maximum functional activity in performing daily activities.
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Maybe this could be the start to something good for the whole contry and other mental conditions as well? One can only hope.