Full Text of HB4737 96th General Assembly
HB4737 96TH GENERAL ASSEMBLY
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96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010 HB4737
Introduced 1/4/2010, by Rep. Betsy Hannig SYNOPSIS AS INTRODUCED: |
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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 | |
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A BILL FOR
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HB4737 |
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LRB096 15482 JAM 30712 b |
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| AN ACT concerning government.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| 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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HB4737 |
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LRB096 15482 JAM 30712 b |
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| (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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HB4737 |
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LRB096 15482 JAM 30712 b |
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| 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.
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