Sen. William R. Haine

Filed: 11/18/2010

 

 


 

 


 
09600SB0336sam001LRB096 06378 JDS 43921 a

1
AMENDMENT TO SENATE BILL 336

2    AMENDMENT NO. ______. Amend Senate Bill 336 by replacing
3everything after the enacting clause with the following:
 
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.

 

 

09600SB0336sam001- 2 -LRB096 06378 JDS 43921 a

1    (b) For the purpose of this Section, "medically necessary"
2means any care, treatment, intervention, service, or item that
3will or is reasonably expected to:
4        (i) prevent the onset of an illness, condition, injury,
5    disease, or disability;
6        (ii) reduce or ameliorate the physical, mental, or
7    developmental effects of an illness, condition, injury,
8    disease, or disability; or
9        (iii) assist the achievement or maintenance of maximum
10    functional activity in performing daily activities.
11    (c) The coverage required under this Section shall be
12subject to the same deductible, coinsurance, waiting period,
13cost sharing limitation, treatment limitation, calendar year
14maximum, or other limitations as provided for other physical or
15rehabilitative or occupational therapy benefits covered by the
16policy.
17    (d) Upon request of the reimbursing insurer, the provider
18of the physical therapy or occupational therapy shall furnish
19medical records, clinical notes, or other necessary data that
20substantiate that initial or continued treatment is medically
21necessary and is resulting in approved clinical status. When
22treatment is anticipated to require continued services to
23achieve demonstrable progress, the insurer may request a
24treatment plan consisting of the diagnosis, proposed treatment
25by type, proposed frequency of treatment, anticipated duration
26of treatment, anticipated outcomes stated as goals, and

 

 

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1proposed frequency of updating the treatment plan.
2    (e) When making a determination of medical necessity for
3treatment, an insurer must make the determination in a manner
4consistent with the manner in which that determination is made
5with respect to other diseases or illnesses covered under the
6policy, including an appeals process. During the appeals
7process, any challenge to medical necessity may be viewed as
8reasonable only if the review includes a licensed health care
9professional with the same category of license as the
10professional who ordered or referred the service in question
11and with expertise in the most current and effective treatment.
12(Source: P.A. 96-1227, eff. 1-1-11.)
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.".