Illinois Autism Insurance Coalition

Resources related to accessing intensive behavioral treatments, such as ABA , for autism, developmental disabilities and mental health disorders for all stakeholders: individuals with ASD/DD/MH and their families, employers, insurance carriers, legislators, providers, government, regulators, advocates and educators.

ABA in Plans

Self-Insured ERISA Employer-Sponsored Group Plans Resources

Grandfathered Health Plans – Fully Funded Employer-Sponsored Group and Individual and Family Broker Plans (authored prior to the Affordable Healthcare Act) Illinois Autism Mandate Law

  • Children under the age of 21 will receive coverage for the diagnosis and treatment of autism spectrum disorders.
  • The law also requires coverage for the following treatments:
    • Psychiatric care provided by a licensed psychiatrist;
    • Psychological care provided by a licensed psychologist;
    • Habilitative or rehabilitative care -counseling and treatment programs intended to develop, maintain, and restore the functioning of an individual, including Applied Behavioral Analysis (ABA);
    • 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 and Sensory processing.
    • A simple breakdown of the mandate: Illinois Autism Mandate Law and Benefit
  • Illinois Autism Mandate Language
    • Link to Illinois Statue 215, Autism Mandate passed in 2008 (215 ILCS 5/356z.14)
    • IL Mandate Expanded for other Diagnosis 2009 (2) The Illinois Statue 215 amendment in 2009 added habilitative services for children less than 19 years of age with a congenital, genetic or early acquired disorder, including autism spectrum disorders. (215 ILCS 5/356z.15)
    • Illinois Department of Insurance – Autism Benefit FAQ

Non-Grandfathered Health Plans (authored after ACA) have autism benefits under the Essential Healthcare Package with no age limits or caps.

  • Child-Only & Family ACA Exchange Marketplace Plans
    • ACA Exchange child-only plans and qualifying for subsidies
        • If your child has access to an employer-sponsored plan, you will not be eligible for a discounted (subsidy) Marketplace plan but you can still purchase a non-discounted child-only Marketplace plan. Some plans allow you to carry more than one policy while others do not.
        • Who is eligible for subsidies?
        • What are Essential Health Benefits?
        • A child-only policy may be a good option if:
          • the child lives with grandparents who do not have private insurance because they are eligible for Medicare, and the child is not eligible for Medicaid or the Children’s Health Insurance Program.
          • Parents who are divorced or live in different states.
          • Families affected by autism whose job-based coverage does not include ABA.
          • Individuals with autism who do not qualify for Medicaid
      • What health insurance providers are selling plans on the exchange in Illinois for 2012
        • Celtic Insurance Company (Celtic) – (HMO)
        • CIGNA HealthCare of Illinois, Inc. (CIGNA)
        • (HMO) – Quartz Health Benefit Plans Corporation (Quartz)
        • (HMO) – Health Alliance Medical Plans, Inc. (HAMP)
        • (HMO and POS) – Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC, aka Blue Cross Blue Shield)
      • The 4 Medal Plans:  https://www.healthcare.gov/choose-a-plan/plans-categories/
        Plan Category          The insurance company pays               You pay

        Bronze                                      | 60%                                                 | 40%
        Silver                                         | 70%                                                 | 30%
        Gold                                           | 80%                                                 | 20%
        Platinum                                 | 90%                                                 | 10%
      • Enroll on ACA Exchange Plans by connecting with Get Covered Illinois (GCI) Helpdesk at 1-866-311-1119 or, visit GetCoveredIllinois.gov.
      • The average rate change across all rating areas is a 4% decrease.
        2020 monthly premium is $420 minus any qualifications for premium tax credit and CSRs or cost sharing reduction
      • Map of Insurers and detailed rate information https://insurance.illinois.gov/Newsrls/2019/10/2020ILRatePlanAnalysis.pdf
  • Broker Child-only Plans
    • These plans can be purchased off the ACA exchange in the individual and family insurance market through a Broker. Find an insurance broker to help you find more information.
  • Fully Funded Employer-Sponsored Group Plans authored after the ACA
    • Your employer’s health plan will offer an ABA benefit based on compliance with the ACA. Ask your employer for your benefits summary plan or manual and look for the medical necessity definition for Autism Spectrum Disorder.

Medicaid Public Health Plan

  • Medicaid State Health Plan
    • For children ages 0 through 20 years old, currently, Medicaid does not have an ABA benefit to fund treatment.  See our page on “Public Policy Initiatives”
    • For adults ages 21 years and over, currently, Medicaid does not have an ABA benefit to fund treatment.  See our page on “Public Policy Initiatives.” We would encourage you to explore PSR services in the Medicaid community mental health services offered by a community mental health center. Learn more
  • Medicaid Waiver’s Behavior Intervention & Treatment Services (56U) through the Division of Developmental Disabilities.
    • Level 1 Providers are licensed clinical psychologist or certified behavior analyst (BCBA)
    • Level 2 Providers are certified assistant behavior analyst (BCaBA) or other provider types meeting training and experience requirements.
    • IL 56U Behavior Services Info

Medical Necessity – Elements

  • Common characteristics of Medical Necessity
  • Illinois Autism Mandate Medical Necessity Language – “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.

ABA Treatment and Clinical Structure

Illinois Department of Insurance

Speech & Occupational Therapy

 

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