Friday, June 11, 2010

State Success: Securing Preventive Physical Therapy Coverage in Illinois

Currently, no treatment exists to reverse the damage multiple sclerosis causes upon the central nervous system. Medications may slow disease progression, but nothing exists to eradicate it. Physical therapy has been clinically proven to help individuals with MS maintain current mobility and muscular strength.

Many insurers generally only pay for physical therapy for restorative purposes, recovery from surgery, fractures, etc. Once a patient reaches a plateau, i.e. improvement ceases, those insurers decline coverage for the physical therapy.

Two Illinois Public Acts - 94-1076 created in 2006 and 96-0139 created on August 7, 2009 - mandate insurance coverage for preventative physical therapy for Illinois citizens with multiple sclerosis, for specific health plans that include:
  • Fully-insured health plans, and
  • State, county, and municipally sponsored self-insured health plans.
Excluded from this state regulation are other self-insured health plans, regulated by the Employee Retirement Income Security Act (ERISA).

Public Act 94-1076 legislates 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 this amendatory Act of the 94th General Assembly must provide coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis.

For purposes of this Section, “preventative physical therapy” means physical therapy that is prescribed by a physician licensed to practice medicine in all of its branches for the purpose of treating parts of the body affected by multiple sclerosis, but only where the physical therapy includes reasonably defined goals, including, but not limited to, sustaining the level of function the person has achieved, with periodic evaluation of the efficacy of the physical therapy against those goals.

Public Act 96-0139 amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis.

Key strategies and tactics pursued included:
  • Soliciting the House Speaker’s participation and support to assure accuracy, momentum and bipartisan support for both pieces of legislation.
  • Seeking a sponsor within the State Senate, diagnosed with MS, and a co-sponsor in the State Assembly for each piece of legislation.
  • Identifying a bill sponsor in the Senate from the majority party to enhance the movement of the bills and to ensure bi-partisan support.
  • Recruiting grassroots activists to attend the Illinois Public Policy Network MS Action Day and seek additional authors.
  • Leveraging the MS Activist Network to reach Illinois State Legislators and engaging grassroots activists.

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