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


Sen. Terry Link

Filed: 5/6/2016





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2    AMENDMENT NO. ______. Amend Senate Bill 2596 by replacing
3everything after the enacting clause with the following:
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



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



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1anticipated duration of treatment, anticipated outcomes stated
2as goals, and proposed frequency of updating the treatment
4    (e) When making a determination of medical necessity for
5treatment, an insurer must make the determination in a manner
6consistent with the manner in which that determination is made
7with respect to other diseases or illnesses covered under the
8policy, including an appeals process. During the appeals
9process, any challenge to medical necessity may be viewed as
10reasonable only if the review includes a licensed health care
11professional with the same category of license as the
12professional who ordered or referred the service in question
13and with expertise in the most current and effective treatment.
14(Source: P.A. 96-1227, eff. 1-1-11; 97-604, eff. 8-26-11.)".