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1 | AN ACT concerning government.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | 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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1 | (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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1 | 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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