*LRB09606378JAM16462b* SB0336 96THEngrossed GENERALLRB096 ASSEMBLY06378 StateJAM of16462 Illinoisb andAN 2010ACT SB0336concerning Introducedgovernment. 2/6/2009, by Sen.

John J.

Cullerton SYNOPSIS AS INTRODUCED:

ILCS 290/0.1 from Ch.

53, par.

0.1 concerning the short title.

Makes a technical change in the Section LRB096 06378 JAM 16462 b A BILL FOR SB0336 LRB096 06378 JAM 16462 b AN ACT concerning government.

The SalariesState Employees Group Insurance Act of 1971 is amended by changing Section 0.16.11A as follows:

(5 ILCS 290/0.1)375/6.11A) (fromSec. Ch.

53,6.11A. par.

0.1)Physical Sec.therapy and occupational therapy.

0.1.(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.

Short(b) title.For the purpose of this Section, "medically necessary" means any care, treatment, intervention, service, or item that will or is reasonably expected to:

This(i) Actprevent maythe beonset citedof asan theillness, thecondition, Salariesinjury, Act.disease, or disability;

(ii) reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, SB0336 Engrossed - 2 - LRB096 06378 JAM 16462 b 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 SB0336 Engrossed - 3 - LRB096 06378 JAM 16462 b 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.

89-233,96-1227, eff.

1-1-96.)1-1-11.) Section 99.

Effective date.

This Act takes effect upon becoming law.