Rep. Betsy Hannig
Filed: 2/24/2010
 
 

 




 

 		












09600HB4737ham001

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AMENDMENT TO HOUSE BILL 4737 




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    AMENDMENT NO. ______. Amend House Bill 4737 by replacing 
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everything after the enacting clause with the following:

 
 
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    "Section 5. The State Employees Group Insurance Act of 1971 
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is amended  by adding Section 6.11A as follows:
 
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    (5 ILCS 375/6.11A new)
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    Sec. 6.11A. Preventative physical therapy and occupational 
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therapy.
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    (a) The program of health benefits provided under this Act 
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shall provide coverage for medically necessary physical 
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therapy and occupational therapy prescribed by a physician 
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licensed under the Medical Practice Act of 1987, a physician's 
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assistant licensed under the Physician's Assistant Practice 
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Act of 1987, or an advance practice nurse licensed under the 
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Nurse Practice Act.
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    (b) For the purpose of this Section, "medically necessary" 
 


 






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means any care, treatment, intervention, service, or item that 
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will or is reasonably expected to:
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                (i) prevent the onset of an illness, 
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            condition, injury, disease, or disability;
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                (ii) reduce or ameliorate the physical, 
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            mental, or developmental effects of an illness, 
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            condition, injury, disease, or disability; or
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                (iii) assist the achievement or maintenance of 
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            maximum functional activity in performing daily 
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            activities.
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    (c) The coverage required under this Section shall be 
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subject to the same deductible, coinsurance, waiting period, 
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cost sharing limitation, treatment limitation, calendar year 
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maximum, or other limitations as provided for other physical or 
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rehabilitative or occupational therapy benefits covered by the 
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policy.
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    (d) Upon request of the reimbursing insurer, the provider 
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of the physical therapy or occupational therapy shall furnish 
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medical records, clinical notes, or other necessary data that 
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substantiate that initial or continued treatment is medically 
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necessary and is resulting in approved clinical status. When 
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treatment is anticipated to require continued services to 
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achieve demonstrable progress, the insurer may request a 
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treatment plan consisting of the diagnosis, proposed treatment 
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by type, proposed frequency of treatment, anticipated duration 
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of treatment, anticipated outcomes stated as goals, and 
 


 






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proposed frequency of updating the treatment plan.
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    (e) When making a determination of medical necessity for 
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treatment, an insurer must make the determination in a manner 
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consistent with the manner in which that determination is made 
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with respect to other diseases or illnesses covered under the 
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policy, including an appeals process. During the appeals 
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process, any challenge to medical necessity may be viewed as 
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reasonable only if the review includes a licensed health care 
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professional with the same category of license as the 
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prescriber of the service in question and with expertise in the 
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most current and effective treatment.".