Bill Text: IL SB2596 | 2015-2016 | 99th General Assembly | Engrossed
Bill Title: Amends the Illinois Insurance Code. Provides that a group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed after the effective date of the amendatory Act must provide coverage for medically necessary preventative physical or rehabilitative therapy for insureds diagnosed with multiple sclerosis without any treatment limitation or calendar year maximum as determined by the patient's treating physician. Makes changes to the provision's definition of "preventative physical therapy" to include physical and other rehabilitative therapy. Removes requirements that coverage under this provision be subject to the same coinsurance, waiting period, cost sharing limitation, treatment limitation, calendar year maximum, or other limitation as provided for other physical or rehabilitative therapy benefits.
Spectrum: Partisan Bill (Democrat 20-1)
Status: (Engrossed - Dead) 2016-06-30 - Rule 19(a) / Re-referred to Rules Committee [SB2596 Detail]
Download: Illinois-2015-SB2596-Engrossed.html
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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||
5 | is amended by changing Section 6.11A as follows:
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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 | ||||||
17 | multiple sclerosis shall be governed by the Illinois Essential | ||||||
18 | Health Benefits plan. | ||||||
19 | (b) For the purpose of this Section, "medically necessary" | ||||||
20 | means any care, treatment, intervention, service, or item that | ||||||
21 | will or is reasonably expected to: | ||||||
22 | (i) prevent the onset of an illness, condition, injury, | ||||||
23 | disease, or disability; |
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1 | (ii) reduce or ameliorate the physical, mental, or | ||||||
2 | developmental effects of an illness, condition, injury, | ||||||
3 | disease, or disability; or | ||||||
4 | (iii) assist the achievement or maintenance of maximum | ||||||
5 | functional activity in performing daily activities. | ||||||
6 | (c) The coverage required under this Section shall be | ||||||
7 | subject to the same deductible, coinsurance, waiting period, | ||||||
8 | cost sharing limitation, treatment limitation, calendar year | ||||||
9 | maximum, or other limitations as provided for other physical or | ||||||
10 | rehabilitative or occupational therapy benefits covered by the | ||||||
11 | policy. | ||||||
12 | (d) Upon request of the reimbursing insurer, the provider | ||||||
13 | of the physical therapy or occupational therapy shall furnish | ||||||
14 | medical records, clinical notes, or other necessary data that | ||||||
15 | substantiate that initial or continued treatment is medically | ||||||
16 | necessary. When treatment is anticipated to require continued | ||||||
17 | services to achieve demonstrable progress, the insurer may | ||||||
18 | request a treatment plan consisting of the diagnosis, proposed | ||||||
19 | treatment by type, proposed frequency of treatment, | ||||||
20 | anticipated duration of treatment, anticipated outcomes stated | ||||||
21 | as goals, and proposed frequency of updating the treatment | ||||||
22 | plan. | ||||||
23 | (e) When making a determination of medical necessity for | ||||||
24 | treatment, an insurer must make the determination in a manner | ||||||
25 | consistent with the manner in which that determination is made | ||||||
26 | with respect to other diseases or illnesses covered under the |
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1 | policy, including an appeals process. During the appeals | ||||||
2 | process, any challenge to medical necessity may be viewed as | ||||||
3 | reasonable only if the review includes a licensed health care | ||||||
4 | professional with the same category of license as the | ||||||
5 | professional who ordered or referred the service in question | ||||||
6 | and with expertise in the most current and effective treatment.
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7 | (Source: P.A. 96-1227, eff. 1-1-11; 97-604, eff. 8-26-11.)
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