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1 | AN ACT concerning insurance.
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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 Illinois Insurance Code is amended by | |||||||||||||||||||
5 | changing Section 356w as follows:
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6 | (215 ILCS 5/356w)
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7 | Sec. 356w. Diabetes self-management training and | |||||||||||||||||||
8 | education.
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9 | (a) A group policy of accident and health insurance that is | |||||||||||||||||||
10 | amended,
delivered,
issued, or renewed after the
effective date | |||||||||||||||||||
11 | of this amendatory Act of 1998 shall provide coverage for
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12 | outpatient self-management
training and education, equipment, | |||||||||||||||||||
13 | and supplies, as set forth in this Section,
for the treatment | |||||||||||||||||||
14 | of type 1 diabetes, type 2 diabetes, and gestational diabetes
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15 | mellitus.
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16 | (b) As used in this Section:
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17 | "Diabetes self-management training"
means instruction in | |||||||||||||||||||
18 | an outpatient setting
which enables a diabetic patient to | |||||||||||||||||||
19 | understand the diabetic management process
and daily | |||||||||||||||||||
20 | management of
diabetic therapy as a means of avoiding frequent | |||||||||||||||||||
21 | hospitalization and
complications. Diabetes self-management | |||||||||||||||||||
22 | training shall include
the content areas listed in the National | |||||||||||||||||||
23 | Standards for Diabetes Self-Management
Education Programs as |
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1 | published by the American Diabetes Association, including
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2 | medical nutrition therapy.
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3 | "Medical nutrition therapy" shall have the meaning
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4 | ascribed to "medical nutrition care" in the Dietetic and | ||||||
5 | Nutrition Services
Practice Act.
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6 | "Physician" means a
physician licensed to practice | ||||||
7 | medicine in all of
its branches providing care to the | ||||||
8 | individual.
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9 | "Qualified provider" for an
individual that is enrolled in:
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10 | (1) a health maintenance organization that uses a
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11 | primary
care physician to
control access to specialty care | ||||||
12 | means (A) the individual's primary care
physician licensed | ||||||
13 | to practice
medicine in all of its branches, (B) a | ||||||
14 | physician licensed to practice
medicine in all of its | ||||||
15 | branches to
whom the individual has been referred by the | ||||||
16 | primary care physician, or (C) a
certified, registered, or
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17 | licensed network health care professional with expertise | ||||||
18 | in diabetes management
to whom the individual
has been | ||||||
19 | referred by the primary care physician.
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20 | (2) an insurance plan
means (A) a physician licensed to | ||||||
21 | practice medicine in
all of its branches or (B) a
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22 | certified, registered, or licensed health care | ||||||
23 | professional with expertise in
diabetes management to whom | ||||||
24 | the individual has been referred by a physician.
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25 | (c) Coverage under this Section for diabetes | ||||||
26 | self-management training,
including medical nutrition
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1 | education, shall be limited to the following:
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2 | (1) Up to 3 medically necessary visits to a qualified | ||||||
3 | provider upon
initial diagnosis of diabetes
by the | ||||||
4 | patient's
physician or, if diagnosis of diabetes was made | ||||||
5 | within one year prior to the
effective date of
this | ||||||
6 | amendatory Act
of 1998 where the insured was a covered | ||||||
7 | individual, up to 3 medically necessary
visits to a | ||||||
8 | qualified provider within one
year after that
effective
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9 | date.
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10 | (2) Up to 2 medically necessary visits to a qualified | ||||||
11 | provider upon a
determination by a
patient's
physician that | ||||||
12 | a significant change in the patient's symptoms or medical
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13 | condition has
occurred. A "significant change" in | ||||||
14 | condition means symptomatic
hyperglycemia (greater than | ||||||
15 | 250 mg/dl on repeated occasions), severe
hypoglycemia | ||||||
16 | (requiring the assistance of another person), onset or | ||||||
17 | progression
of diabetes, or a significant change in medical | ||||||
18 | condition that would require a
significantly different | ||||||
19 | treatment regimen.
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20 | Payment by the insurer or health maintenance organization | ||||||
21 | for the coverage
required for diabetes self-management | ||||||
22 | training pursuant to the provisions of
this Section is only | ||||||
23 | required to be made for services provided.
No coverage is | ||||||
24 | required for additional visits beyond those specified in items
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25 | (1) and (2) of this subsection.
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26 | Coverage under this subsection (c) for diabetes |
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1 | self-management training
shall
be subject to the same
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2 | deductible, co-payment, and co-insurance provisions that apply | ||||||
3 | to coverage
under
the policy for other
services provided by the | ||||||
4 | same type of provider.
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5 | (d) Coverage shall be provided for the following
equipment | ||||||
6 | when medically necessary
and prescribed by a physician licensed | ||||||
7 | to practice medicine in all
of its branches.
Coverage for the | ||||||
8 | following items shall be subject to deductible, co-payment
and | ||||||
9 | co-insurance provisions
provided for under the policy or a | ||||||
10 | durable medical equipment rider to the
policy:
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11 | (1) blood glucose monitors;
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12 | (2) blood glucose monitors for the legally blind;
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13 | (3) cartridges for the legally blind; and
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14 | (4) lancets and lancing devices ; and .
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15 | (5) test strips for glucose monitors. | ||||||
16 | This subsection does not apply to a group policy of | ||||||
17 | accident and health
insurance that does not provide a durable | ||||||
18 | medical equipment benefit.
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19 | (e) Coverage shall be provided for the following | ||||||
20 | pharmaceuticals and
supplies when
medically necessary and | ||||||
21 | prescribed by a physician licensed to
practice medicine in all | ||||||
22 | of its
branches.
Coverage for the following items shall be | ||||||
23 | subject to the same coverage,
deductible,
co-payment, and | ||||||
24 | co-insurance
provisions under the policy or a drug rider to the | ||||||
25 | policy:
| ||||||
26 | (1) insulin;
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1 | (2) syringes and needles;
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2 | (3) test strips for glucose monitors;
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3 | (3) (4) FDA approved oral agents used to control blood | ||||||
4 | sugar; and
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5 | (4) (5) glucagon emergency kits.
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6 | This subsection does not apply to a group policy of | ||||||
7 | accident and health
insurance that does not provide a drug | ||||||
8 | benefit.
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9 | (f) Coverage shall be provided for regular foot care exams | ||||||
10 | by a
physician or by a
physician to whom a physician has | ||||||
11 | referred the patient. Coverage
for regular foot care exams
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12 | shall be subject to the same deductible, co-payment, and | ||||||
13 | co-insurance
provisions
that apply under the policy for
other | ||||||
14 | services provided by the same type of provider.
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15 | (g) If authorized by a physician, diabetes self-management
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16 | training may be provided as a part of an office visit, group | ||||||
17 | setting, or home
visit.
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18 | (h) This Section shall not apply to agreements, contracts, | ||||||
19 | or policies that
provide coverage for a specified diagnosis or | ||||||
20 | other limited benefit coverage.
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21 | (Source: P.A. 90-741, eff. 1-1-99.)
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22 | Section 99. Effective date. This Act takes effect upon | ||||||
23 | becoming law.
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