| ||||
| Public Act 096-1227 | ||||
| ||||
| ||||
AN ACT concerning government.
| ||||
Be it enacted by the People of the State of Illinois,
| ||||
represented in the General Assembly:
| ||||
Section 5. The State Employees Group Insurance Act of 1971 | ||||
is amended by adding Section 6.11A as follows: | ||||
(5 ILCS 375/6.11A new) | ||||
Sec. 6.11A. Physical therapy and occupational therapy. | ||||
(a) The program of health benefits provided under this Act | ||||
shall provide coverage for medically necessary physical | ||||
therapy and occupational therapy ordered or referred by a | ||||
physician licensed under the Medical Practice Act of 1987, a | ||||
physician's assistant licensed under the Physician's Assistant | ||||
Practice Act of 1987, or an advanced practice nurse licensed | ||||
under the Nurse Practice Act. | ||||
(b) For the purpose of this Section, "medically necessary" | ||||
means any care, treatment, intervention, service, or item that | ||||
will or is reasonably expected to: | ||||
(i) prevent the onset of an illness, | ||||
condition, injury, disease, or disability; | ||||
(ii) reduce or ameliorate the physical, | ||||
mental, or developmental effects of an illness, | ||||
condition, injury, disease, or disability; or | ||||
(iii) assist the achievement or maintenance of | ||||
maximum functional activity in performing daily | ||
activities. | ||
(c) The coverage required under this Section shall be | ||
subject to the same deductible, coinsurance, waiting period, | ||
cost sharing limitation, treatment limitation, calendar year | ||
maximum, or other limitations as provided for other physical or | ||
rehabilitative or occupational therapy benefits covered by the | ||
policy. | ||
(d) Upon request of the reimbursing insurer, the provider | ||
of the physical therapy or occupational therapy shall furnish | ||
medical records, clinical notes, or other necessary data that | ||
substantiate that initial or continued treatment is medically | ||
necessary and is resulting in approved clinical status. When | ||
treatment is anticipated to require continued services to | ||
achieve demonstrable progress, the insurer may request a | ||
treatment plan consisting of the diagnosis, proposed treatment | ||
by type, proposed frequency of treatment, anticipated duration | ||
of treatment, anticipated outcomes stated as goals, and | ||
proposed frequency of updating the treatment plan. | ||
(e) When making a determination of medical necessity for | ||
treatment, an insurer must make the determination in a manner | ||
consistent with the manner in which that determination is made | ||
with respect to other diseases or illnesses covered under the | ||
policy, including an appeals process. During the appeals | ||
process, any challenge to medical necessity may be viewed as | ||
reasonable only if the review includes a licensed health care | ||
professional with the same category of license as the | ||
professional who ordered or referred the service in question | ||
and with expertise in the most current and effective treatment.
| ||