96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB4737

 

Introduced 1/4/2010, by Rep. Betsy Hannig

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11A new

    Amends the State Employees Group Insurance Act of 1971. Requires that the Act's health benefits program include coverage of medically necessary physical therapy that is aimed at sustaining a reasonably achievable level of functioning. Defines terms and specifies rights and duties of the insurer.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1     AN ACT concerning government.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The State Employees Group Insurance Act of 1971
5 is amended by adding Section 6.11A as follows:
 
6     (5 ILCS 375/6.11A new)
7     Sec. 6.11A. Preventative physical therapy.
8     (a) The program of health benefits provided under this Act
9 shall provide coverage for medically necessary physical
10 therapy.
11     (b) For the purposes of this Section:
12         (1) "Physical therapy" means physical therapy:
13                 (i) that is prescribed by a physician licensed
14             under the Medical Practice Act of 1987;
15                 (ii) that is provided by (A) a physician
16             licensed under the Medical Practice Act of 1987,
17             (B) a physician's assistant licensed under the
18             Physician's Assistant Practice Act of 1987, (C) a
19             nurse licensed under the Nurse Practice Act, (D) a
20             physical therapist licensed under the Illinois
21             Physical Therapy Act, or (E) an occupational
22             therapist licensed under the Illinois Occupational
23             Therapy Act;

 

 

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1                 (iii) that is for the purpose of treating parts
2             of the body affected by an illness, condition,
3             injury, disease, or disability; and
4                 (iv) that includes reasonably defined goals,
5             including, but not limited to, sustaining the
6             level of function the person can reasonably
7             achieve, with periodic evaluation of the efficacy
8             of the physical therapy against those goals.
9         (2) "Medically necessary" means any care, treatment,
10     intervention, service, or item that will or is reasonably
11     expected to:
12                 (i) prevent the onset of an illness,
13             condition, injury, disease, or disability;
14                 (ii) reduce or ameliorate the physical,
15             mental, or developmental effects of an illness,
16             condition, injury, disease, or disability; or
17                 (iii) assist the achievement or maintenance of
18             maximum functional activity in performing daily
19             activities.
20     (c) The coverage required under this Section shall be
21 subject to the same deductible, coinsurance, waiting period,
22 cost sharing limitation, treatment limitation, calendar year
23 maximum, or other limitations as provided for other physical or
24 rehabilitative therapy benefits covered by the policy.
25     (d) Upon request of the reimbursing insurer, a physician
26 who prescribes physical therapy or the provider of the

 

 

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1 prescribed treatment shall furnish medical records, clinical
2 notes, or other necessary data that substantiate that initial
3 or continued treatment is medically necessary and is resulting
4 in approved clinical status. When treatment is anticipated to
5 require continued services to achieve demonstrable progress,
6 the insurer may request a treatment plan consisting of the
7 diagnosis, proposed treatment by type, proposed frequency of
8 treatment, anticipated duration of treatment, anticipated
9 outcomes stated as goals, and proposed frequency of updating
10 the treatment plan.
11     (e) When making a determination of medical necessity for
12 treatment, an insurer must make the determination in a manner
13 consistent with the manner in which that determination is made
14 with respect to other diseases or illnesses covered under the
15 policy, including an appeals process. During the appeals
16 process, any challenge to medical necessity may be viewed as
17 reasonable only if the review includes a physician, physical
18 therapist, and occupational therapist with expertise in the
19 most current and effective treatment.