Rep. Betsy Hannig

Filed: 2/24/2010

 

 


 

 


 
09600HB4737ham001 LRB096 15482 JAM 37224 a

1
AMENDMENT TO HOUSE BILL 4737

2     AMENDMENT NO. ______. Amend House Bill 4737 by replacing
3 everything after the enacting clause with the following:
 
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 and occupational
8 therapy.
9     (a) The program of health benefits provided under this Act
10 shall provide coverage for medically necessary physical
11 therapy and occupational therapy prescribed by a physician
12 licensed under the Medical Practice Act of 1987, a physician's
13 assistant licensed under the Physician's Assistant Practice
14 Act of 1987, or an advance practice nurse licensed under the
15 Nurse Practice Act.
16     (b) For the purpose of this Section, "medically necessary"

 

 

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

 

 

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1 proposed frequency of updating the treatment plan.
2     (e) When making a determination of medical necessity for
3 treatment, an insurer must make the determination in a manner
4 consistent with the manner in which that determination is made
5 with respect to other diseases or illnesses covered under the
6 policy, including an appeals process. During the appeals
7 process, any challenge to medical necessity may be viewed as
8 reasonable only if the review includes a licensed health care
9 professional with the same category of license as the
10 prescriber of the service in question and with expertise in the
11 most current and effective treatment.".