Rep. Betsy Hannig

Filed: 2/24/2010

 

 


 

 


 
09600HB4737ham002 LRB096 15482 JAM 37585 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. Physical therapy and occupational therapy.
8     (a) The program of health benefits provided under this Act
9 shall provide coverage for medically necessary physical
10 therapy and occupational therapy ordered or referred by a
11 physician licensed under the Medical Practice Act of 1987, a
12 physician's assistant licensed under the Physician's Assistant
13 Practice Act of 1987, or an advanced practice nurse licensed
14 under the Nurse Practice Act.
15     (b) For the purpose of this Section, "medically necessary"
16 means any care, treatment, intervention, service, or item that

 

 

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

 

 

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