SB0336 EngrossedLRB096 06378 JAM 16462 b

1    AN ACT concerning government.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11A as follows:
 
6    (5 ILCS 375/6.11A)
7    Sec. 6.11A. Physical therapy and occupational therapy.
8    (a) The program of health benefits provided under this Act
9shall provide coverage for medically necessary physical
10therapy and occupational therapy when that therapy is ordered
11for the treatment of autoimmune diseases or referred for the
12same purpose by (i) a physician licensed under the Medical
13Practice Act of 1987, (ii) a physician's assistant licensed
14under the Physician's Assistant Practice Act of 1987, or (iii)
15an advanced practice nurse licensed under the Nurse Practice
16Act.
17    (b) For the purpose of this Section, "medically necessary"
18means any care, treatment, intervention, service, or item that
19will or is reasonably expected to:
20        (i) prevent the onset of an illness, condition, injury,
21    disease, or disability;
22        (ii) reduce or ameliorate the physical, mental, or
23    developmental effects of an illness, condition, injury,

 

 

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1    disease, or disability; or
2        (iii) assist the achievement or maintenance of maximum
3    functional activity in performing daily activities.
4    (c) The coverage required under this Section shall be
5subject to the same deductible, coinsurance, waiting period,
6cost sharing limitation, treatment limitation, calendar year
7maximum, or other limitations as provided for other physical or
8rehabilitative or occupational therapy benefits covered by the
9policy.
10    (d) Upon request of the reimbursing insurer, the provider
11of the physical therapy or occupational therapy shall furnish
12medical records, clinical notes, or other necessary data that
13substantiate that initial or continued treatment is medically
14necessary and is resulting in approved clinical status. When
15treatment is anticipated to require continued services to
16achieve demonstrable progress, the insurer may request a
17treatment plan consisting of the diagnosis, proposed treatment
18by type, proposed frequency of treatment, anticipated duration
19of treatment, anticipated outcomes stated as goals, and
20proposed frequency of updating the treatment plan.
21    (e) When making a determination of medical necessity for
22treatment, an insurer must make the determination in a manner
23consistent with the manner in which that determination is made
24with respect to other diseases or illnesses covered under the
25policy, including an appeals process. During the appeals
26process, any challenge to medical necessity may be viewed as

 

 

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1reasonable only if the review includes a licensed health care
2professional with the same category of license as the
3professional who ordered or referred the service in question
4and with expertise in the most current and effective treatment.
5(Source: P.A. 96-1227, eff. 1-1-11.)
 
6    Section 99. Effective date. This Act takes effect upon
7becoming law.