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| Public Act 097-0604 | ||||
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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 | ||||
is amended by changing Section 6.11A as follows: | ||||
(5 ILCS 375/6.11A) | ||||
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 when that therapy is ordered | ||||
for the treatment of autoimmune diseases or referred for the | ||||
same purpose by (i) a physician licensed under the Medical | ||||
Practice Act of 1987, (ii) a physician's assistant licensed | ||||
under the Physician's Assistant Practice Act of 1987, or (iii) | ||||
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 activities. | ||
(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 | ||
policy. | ||
(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.
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(Source: P.A. 96-1227, eff. 1-1-11.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law. | ||