HB4737 96TH GENERAL ASSEMBLY

LRB096 15482 JAM 30712 b

96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB4737

Introduced 1/4/2010, by Rep. Betsy Hannig

SYNOPSIS AS INTRODUCED:

5 ILCS 375/6.11A new

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.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

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. Preventative physical therapy.

(a) The program of health benefits provided under this Act shall provide coverage for medically necessary physical therapy.

(b) For the purposes of this Section:

(1) "Physical therapy" means physical therapy:

(i) that is prescribed by a physician licensed under the Medical Practice Act of 1987;

(ii) that is provided by (A) a physician licensed under the Medical Practice Act of 1987, (B) a physician's assistant licensed under the Physician's Assistant Practice Act of 1987, (C) a nurse licensed under the Nurse Practice Act, (D) a physical therapist licensed under the Illinois Physical Therapy Act, or (E) an occupational therapist licensed under the Illinois Occupational Therapy Act;

(iii) that is for the purpose of treating parts of the body affected by an illness, condition, injury, disease, or disability; and

(iv) that includes reasonably defined goals, including, but not limited to, sustaining the level of function the person can reasonably achieve, with periodic evaluation of the efficacy of the physical therapy against those goals.

(2) "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 therapy benefits covered by the policy.

(d) Upon request of the reimbursing insurer, a physician who prescribes physical therapy or the provider of the prescribed treatment 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 physician, physical therapist, and occupational therapist with expertise in the most current and effective treatment.