Public Act 097-0604
 
SB1557 EnrolledLRB097 08250 JDS 48376 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 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.

(Source: P.A. 96-1227, eff. 1-1-11.)
 

    Section 99. Effective date. This Act takes effect upon 
becoming law.

Effective Date:  8/26/2011