Full Text of SB2596 99th General Assembly
SB2596eng 99TH GENERAL ASSEMBLY |
| | SB2596 Engrossed | | LRB099 19662 EGJ 44059 b |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The State Employees Group Insurance Act of 1971 | 5 | | is 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 | 9 | | shall provide coverage for medically necessary physical | 10 | | therapy and occupational therapy when that therapy is ordered | 11 | | for the treatment of autoimmune diseases or referred for the | 12 | | same purpose by (i) a physician licensed under the Medical | 13 | | Practice Act of 1987, (ii) a physician's assistant licensed | 14 | | under the Physician's Assistant Practice Act of 1987, or (iii) | 15 | | an advanced practice nurse licensed under the Nurse Practice | 16 | | Act. Physical therapy benefits provided for persons affected by | 17 | | multiple sclerosis shall be governed by the Illinois Essential | 18 | | Health Benefits plan. | 19 | | (b) For the purpose of this Section, "medically necessary" | 20 | | means any care, treatment, intervention, service, or item that | 21 | | will or is reasonably expected to: | 22 | | (i) prevent the onset of an illness, condition, injury, | 23 | | disease, or disability; |
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| 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 | 7 | | subject to the same deductible, coinsurance, waiting period, | 8 | | cost sharing limitation, treatment limitation, calendar year | 9 | | maximum, or other limitations as provided for other physical or | 10 | | rehabilitative or occupational therapy benefits covered by the | 11 | | policy. | 12 | | (d) Upon request of the reimbursing insurer, the provider | 13 | | of the physical therapy or occupational therapy shall furnish | 14 | | medical records, clinical notes, or other necessary data that | 15 | | substantiate that initial or continued treatment is medically | 16 | | necessary. When treatment is anticipated to require continued | 17 | | services to achieve demonstrable progress, the insurer may | 18 | | request a treatment plan consisting of the diagnosis, proposed | 19 | | treatment by type, proposed frequency of treatment, | 20 | | anticipated duration of treatment, anticipated outcomes stated | 21 | | as goals, and proposed frequency of updating the treatment | 22 | | plan. | 23 | | (e) When making a determination of medical necessity for | 24 | | treatment, an insurer must make the determination in a manner | 25 | | consistent with the manner in which that determination is made | 26 | | with respect to other diseases or illnesses covered under the |
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| 1 | | policy, including an appeals process. During the appeals | 2 | | process, any challenge to medical necessity may be viewed as | 3 | | reasonable only if the review includes a licensed health care | 4 | | professional with the same category of license as the | 5 | | professional who ordered or referred the service in question | 6 | | and 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.)
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