Illinois General Assembly - Full Text of SB2596
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Full Text of SB2596  99th General Assembly




SB2596 EngrossedLRB099 19662 EGJ 44059 b

1    AN ACT concerning regulation.
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. Physical therapy benefits provided for persons affected by
17multiple sclerosis shall be governed by the Illinois Essential
18Health Benefits plan.
19    (b) For the purpose of this Section, "medically necessary"
20means any care, treatment, intervention, service, or item that
21will or is reasonably expected to:
22        (i) prevent the onset of an illness, condition, injury,
23    disease, or disability;



SB2596 Engrossed- 2 -LRB099 19662 EGJ 44059 b

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



SB2596 Engrossed- 3 -LRB099 19662 EGJ 44059 b

1policy, including an appeals process. During the appeals
2process, any challenge to medical necessity may be viewed as
3reasonable only if the review includes a licensed health care
4professional with the same category of license as the
5professional who ordered or referred the service in question
6and with expertise in the most current and effective treatment.
7(Source: P.A. 96-1227, eff. 1-1-11; 97-604, eff. 8-26-11.)