Full Text of HB4737 96th General Assembly
HB4737eng 96TH GENERAL ASSEMBLY
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| AN ACT concerning government.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| 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. 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 ordered or referred by a | 11 |
| physician licensed under the Medical Practice Act of 1987, a | 12 |
| physician's assistant licensed under the Physician's Assistant | 13 |
| Practice Act of 1987, or an advanced practice nurse licensed | 14 |
| under the Nurse Practice Act. | 15 |
| (b) For the purpose of this Section, "medically necessary" | 16 |
| means any care, treatment, intervention, service, or item that | 17 |
| will or is reasonably expected to: | 18 |
| (i) prevent the onset of an illness, | 19 |
| condition, injury, disease, or disability; | 20 |
| (ii) reduce or ameliorate the physical, | 21 |
| mental, or developmental effects of an illness, | 22 |
| condition, injury, disease, or disability; or | 23 |
| (iii) assist the achievement or maintenance of |
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LRB096 15482 JAM 30712 b |
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| maximum functional activity in performing daily | 2 |
| activities. | 3 |
| (c) The coverage required under this Section shall be | 4 |
| subject to the same deductible, coinsurance, waiting period, | 5 |
| cost sharing limitation, treatment limitation, calendar year | 6 |
| maximum, or other limitations as provided for other physical or | 7 |
| rehabilitative or occupational therapy benefits covered by the | 8 |
| policy. | 9 |
| (d) Upon request of the reimbursing insurer, the provider | 10 |
| of the physical therapy or occupational therapy shall furnish | 11 |
| medical records, clinical notes, or other necessary data that | 12 |
| substantiate that initial or continued treatment is medically | 13 |
| necessary and is resulting in approved clinical status. When | 14 |
| treatment is anticipated to require continued services to | 15 |
| achieve demonstrable progress, the insurer may request a | 16 |
| treatment plan consisting of the diagnosis, proposed treatment | 17 |
| by type, proposed frequency of treatment, anticipated duration | 18 |
| of treatment, anticipated outcomes stated as goals, and | 19 |
| proposed frequency of updating the treatment plan. | 20 |
| (e) When making a determination of medical necessity for | 21 |
| treatment, an insurer must make the determination in a manner | 22 |
| consistent with the manner in which that determination is made | 23 |
| with respect to other diseases or illnesses covered under the | 24 |
| policy, including an appeals process. During the appeals | 25 |
| process, any challenge to medical necessity may be viewed as | 26 |
| reasonable only if the review includes a licensed health care |
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| professional with the same category of license as the | 2 |
| professional who ordered or referred the service in question | 3 |
| and with expertise in the most current and effective treatment.
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