Full Text of HB4737 96th General Assembly
HB4737ham001 96TH GENERAL ASSEMBLY
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Rep. Betsy Hannig
Filed: 2/24/2010
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| AMENDMENT TO HOUSE BILL 4737
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| AMENDMENT NO. ______. Amend House Bill 4737 by replacing | 3 |
| everything after the enacting clause with the following:
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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. Preventative physical therapy and occupational | 8 |
| therapy. | 9 |
| (a) The program of health benefits provided under this Act | 10 |
| shall provide coverage for medically necessary physical | 11 |
| therapy and occupational therapy prescribed by a physician | 12 |
| licensed under the Medical Practice Act of 1987, a physician's | 13 |
| assistant licensed under the Physician's Assistant Practice | 14 |
| Act of 1987, or an advance practice nurse licensed under the | 15 |
| Nurse Practice Act. | 16 |
| (b) For the purpose of this Section, "medically necessary" |
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| means any care, treatment, intervention, service, or item that | 2 |
| will or is reasonably expected to: | 3 |
| (i) prevent the onset of an illness, | 4 |
| condition, injury, disease, or disability; | 5 |
| (ii) reduce or ameliorate the physical, | 6 |
| mental, or developmental effects of an illness, | 7 |
| condition, injury, disease, or disability; or | 8 |
| (iii) assist the achievement or maintenance of | 9 |
| maximum functional activity in performing daily | 10 |
| activities. | 11 |
| (c) The coverage required under this Section shall be | 12 |
| subject to the same deductible, coinsurance, waiting period, | 13 |
| cost sharing limitation, treatment limitation, calendar year | 14 |
| maximum, or other limitations as provided for other physical or | 15 |
| rehabilitative or occupational therapy benefits covered by the | 16 |
| policy. | 17 |
| (d) Upon request of the reimbursing insurer, the provider | 18 |
| of the physical therapy or occupational therapy shall furnish | 19 |
| medical records, clinical notes, or other necessary data that | 20 |
| substantiate that initial or continued treatment is medically | 21 |
| necessary and is resulting in approved clinical status. When | 22 |
| treatment is anticipated to require continued services to | 23 |
| achieve demonstrable progress, the insurer may request a | 24 |
| treatment plan consisting of the diagnosis, proposed treatment | 25 |
| by type, proposed frequency of treatment, anticipated duration | 26 |
| of treatment, anticipated outcomes stated as goals, and |
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| proposed frequency of updating the treatment plan. | 2 |
| (e) When making a determination of medical necessity for | 3 |
| treatment, an insurer must make the determination in a manner | 4 |
| consistent with the manner in which that determination is made | 5 |
| with respect to other diseases or illnesses covered under the | 6 |
| policy, including an appeals process. During the appeals | 7 |
| process, any challenge to medical necessity may be viewed as | 8 |
| reasonable only if the review includes a licensed health care | 9 |
| professional with the same category of license as the | 10 |
| prescriber of the service in question and with expertise in the | 11 |
| most current and effective treatment. ".
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