Full Text of SB2596 99th General Assembly
SB2596sam001 99TH GENERAL ASSEMBLY | Sen. Terry Link Filed: 5/6/2016
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| 1 | | AMENDMENT TO SENATE BILL 2596
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2596 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The State Employees Group Insurance Act of 1971 | 5 | | is amended by changing Section 6.11A as follows: | 6 | | (5 ILCS 375/6.11A) | 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 when that therapy is ordered | 11 | | for the treatment of autoimmune diseases or referred for the | 12 | | same purpose by (i) a physician licensed under the Medical | 13 | | Practice Act of 1987, (ii) a physician's assistant licensed | 14 | | under the Physician's Assistant Practice Act of 1987, or (iii) | 15 | | an advanced practice nurse licensed under the Nurse Practice | 16 | | Act. Physical therapy benefits provided for persons affected by |
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| 1 | | multiple sclerosis shall be governed by the Illinois Essential | 2 | | Health Benefits plan. | 3 | | (b) For the purpose of this Section, "medically necessary" | 4 | | means any care, treatment, intervention, service, or item that | 5 | | will or is reasonably expected to: | 6 | | (i) prevent the onset of an illness, condition, injury, | 7 | | disease, or disability; | 8 | | (ii) reduce or ameliorate the physical, mental, or | 9 | | developmental effects of an illness, condition, injury, | 10 | | disease, or disability; or | 11 | | (iii) assist the achievement or maintenance of maximum | 12 | | functional activity in performing daily activities. | 13 | | (c) The coverage required under this Section shall be | 14 | | subject to the same deductible, coinsurance, waiting period, | 15 | | cost sharing limitation, treatment limitation, calendar year | 16 | | maximum, or other limitations as provided for other physical or | 17 | | rehabilitative or occupational therapy benefits covered by the | 18 | | policy. | 19 | | (d) Upon request of the reimbursing insurer, the provider | 20 | | of the physical therapy or occupational therapy shall furnish | 21 | | medical records, clinical notes, or other necessary data that | 22 | | substantiate that initial or continued treatment is medically | 23 | | necessary. When treatment is anticipated to require continued | 24 | | services to achieve demonstrable progress, the insurer may | 25 | | request a treatment plan consisting of the diagnosis, proposed | 26 | | treatment by type, proposed frequency of treatment, |
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| 1 | | anticipated duration of treatment, anticipated outcomes stated | 2 | | as goals, and proposed frequency of updating the treatment | 3 | | plan. | 4 | | (e) When making a determination of medical necessity for | 5 | | treatment, an insurer must make the determination in a manner | 6 | | consistent with the manner in which that determination is made | 7 | | with respect to other diseases or illnesses covered under the | 8 | | policy, including an appeals process. During the appeals | 9 | | process, any challenge to medical necessity may be viewed as | 10 | | reasonable only if the review includes a licensed health care | 11 | | professional with the same category of license as the | 12 | | professional who ordered or referred the service in question | 13 | | and with expertise in the most current and effective treatment.
| 14 | | (Source: P.A. 96-1227, eff. 1-1-11; 97-604, eff. 8-26-11.)".
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