Autism Spectrum Disorder Coverage: Compliance with PA 102-0322

Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Illinois Department of Insurance JB PRITZKER Governor ANN GILLESPIE Acting Director TO: All Companies Writing Accident and Health Insurance and Managed Care Plans in Illinois FROM: Ann Gillespie, Acting Director DATE: December 4, 2024 RE: Company Bulletin 2024-17 – Autism Spectrum Disorder Coverage: Compliance with PA 102-0322 _________________________________________________________________________________ The purpose of this Bulletin is to provide guidance to remind issuers that Public Act 102-0322, which took effect January 1, 2022, states: “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.” In accordance with the statute, sites of treatment for autism spectrum disorder services, such as applied behavior analysis, include non-school, non-home, or non-provider locations. Sites can include both private and public settings. The Department recommends issuers request clarification from the insured and/or provider before approving or rejecting a claim for services in non-traditional settings. This will assist issuers, providers, and consumers when making appropriate care decisions. Lack of clarity could lead to claims rejections, payment or reimbursement delays, and, most importantly, delayed care for beneficiaries who need it the most. Issuers are also encouraged to proactively engage with network providers to provide education on the clean submission of autism spectrum disorder/applied behavioral analysis claims for services performed in a non-traditional setting. Covered individuals who are denied services, procedures, or surgical treatments based on a determination that the service, procedure, or surgical treatment is not medically necessary must be afforded appeal rights under the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act. An issuer cannot apply medical necessity criteria that contradict a statutory requirement, though medical necessity criteria can be applied that establish the circumstances when coverage will be provided based on the covered individual’s circumstances. Issuers are reminded that medical necessity criteria for treatment of mental health conditions, including autism spectrum disorder, must be consistent with generally accepted standards of care, including with respect to setting or site of care. 215 ILCS 5/370c(h)- (i), (k). The Department of Insurance expects issuers to comply with their obligations under the law and will be checking for compliance via form filings, consumer complaints, and market conduct exams. Questions about this Bulletin may be directed to DOI.InfoDesk@illinois.gov.