Illinois General Assembly - Full Text of Public Act 096-1227
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Public Act 096-1227





Public Act 096-1227
HB4737 EnrolledLRB096 15482 JAM 30712 b

    AN ACT concerning government.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The State Employees Group Insurance Act of 1971
is amended by adding Section 6.11A as follows:
    (5 ILCS 375/6.11A new)
    Sec. 6.11A. Physical therapy and occupational therapy.
    (a) The program of health benefits provided under this Act
shall provide coverage for medically necessary physical
therapy and occupational therapy ordered or referred by a
physician licensed under the Medical Practice Act of 1987, a
physician's assistant licensed under the Physician's Assistant
Practice Act of 1987, or an advanced practice nurse licensed
under the Nurse Practice Act.
    (b) For the purpose of this Section, "medically necessary"
means any care, treatment, intervention, service, or item that
will or is reasonably expected to:
                (i) prevent the onset of an illness,
            condition, injury, disease, or disability;
                (ii) reduce or ameliorate the physical,
            mental, or developmental effects of an illness,
            condition, injury, disease, or disability; or
                (iii) assist the achievement or maintenance of
            maximum functional activity in performing daily
    (c) The coverage required under this Section shall be
subject to the same deductible, coinsurance, waiting period,
cost sharing limitation, treatment limitation, calendar year
maximum, or other limitations as provided for other physical or
rehabilitative or occupational therapy benefits covered by the
    (d) Upon request of the reimbursing insurer, the provider
of the physical therapy or occupational therapy shall furnish
medical records, clinical notes, or other necessary data that
substantiate that initial or continued treatment is medically
necessary and is resulting in approved clinical status. When
treatment is anticipated to require continued services to
achieve demonstrable progress, the insurer may request a
treatment plan consisting of the diagnosis, proposed treatment
by type, proposed frequency of treatment, anticipated duration
of treatment, anticipated outcomes stated as goals, and
proposed frequency of updating the treatment plan.
    (e) When making a determination of medical necessity for
treatment, an insurer must make the determination in a manner
consistent with the manner in which that determination is made
with respect to other diseases or illnesses covered under the
policy, including an appeals process. During the appeals
process, any challenge to medical necessity may be viewed as
reasonable only if the review includes a licensed health care
professional with the same category of license as the
professional who ordered or referred the service in question
and with expertise in the most current and effective treatment.

Effective Date: 1/1/2011