Full Text of SB3565 96th General Assembly
SB3565eng 96TH GENERAL ASSEMBLY
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| AN ACT concerning insurance.
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| Be it enacted by the People of the State of Illinois,
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| represented in the General Assembly:
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| Section 5. The Illinois Insurance Code is amended by | 5 |
| changing Section 356w as follows:
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| (215 ILCS 5/356w)
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| Sec. 356w. Diabetes self-management training and | 8 |
| education.
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| (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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| 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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| mellitus.
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| (b) As used in this Section:
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| "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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| published by the American Diabetes Association, including
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| medical nutrition therapy.
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| "Medical nutrition therapy" shall have the meaning
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| ascribed to "medical nutrition care" in the Dietetic and | 5 |
| Nutrition Services
Practice Act.
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| "Physician" means a
physician licensed to practice | 7 |
| medicine in all of
its branches providing care to the | 8 |
| individual.
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| "Qualified provider" for an
individual that is enrolled in:
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| (1) a health maintenance organization that uses a
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| 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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| 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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| (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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| 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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| (c) Coverage under this Section for diabetes | 26 |
| self-management training,
including medical nutrition
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| education, shall be limited to the following:
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| (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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| date.
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| (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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| 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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| 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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| (1) and (2) of this subsection.
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| Coverage under this subsection (c) for diabetes |
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| self-management training
shall
be subject to the same
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| 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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| (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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| (1) blood glucose monitors;
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| (2) blood glucose monitors for the legally blind;
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| (3) cartridges for the legally blind; and
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| (4) lancets and lancing devices.
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| This subsection does not apply to a group policy of | 16 |
| accident and health
insurance that does not provide a durable | 17 |
| medical equipment benefit.
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| (e) Coverage shall be provided for the following | 19 |
| pharmaceuticals and
supplies when
medically necessary and | 20 |
| prescribed by a physician licensed to
practice medicine in all | 21 |
| of its
branches.
Coverage for the following items shall be | 22 |
| subject to the same coverage,
deductible,
co-payment, and | 23 |
| co-insurance
provisions under the policy or a drug rider to the | 24 |
| policy:
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| (1) insulin;
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| (2) syringes and needles;
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| (3) test strips for glucose monitors;
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| (4) FDA approved oral agents used to control blood | 3 |
| sugar; and
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| (5) glucagon emergency kits ; and .
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| (6) the treatment of pain associated with | 6 |
| complications of diabetes, including, but not limited to, | 7 |
| diabetic peripheral neuropathy. | 8 |
| This subsection does not apply to a group policy of | 9 |
| accident and health
insurance that does not provide a drug | 10 |
| benefit.
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| (f) Coverage shall be provided for regular foot care exams | 12 |
| by a
physician or by a
physician to whom a physician has | 13 |
| referred the patient. Coverage
for regular foot care exams
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| shall be subject to the same deductible, co-payment, and | 15 |
| co-insurance
provisions
that apply under the policy for
other | 16 |
| services provided by the same type of provider.
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| (g) If authorized by a physician, diabetes self-management
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| training may be provided as a part of an office visit, group | 19 |
| setting, or home
visit.
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| (h) This Section shall not apply to agreements, contracts, | 21 |
| or policies that
provide coverage for a specified diagnosis or | 22 |
| other limited benefit coverage.
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| (Source: P.A. 90-741, eff. 1-1-99.)
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