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90_HB1142eng
215 ILCS 5/356t new
215 ILCS 5/370s new
215 ILCS 5/511.114 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/3009 from Ch. 73, par. 1503-9
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act. Requires coverage
under those Acts to include diabetes self-management training
and education. Effective immediately.
LRB9005064JScc
HB1142 Engrossed LRB9005064JScc
1 AN ACT concerning health coverage for treatment of
2 diabetes, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Sections 356t, 370s, and 511.114 as follows:
7 (215 ILCS 5/356t new)
8 Sec. 356t. Diabetes self-management training and
9 education.
10 (a) An individual or group policy of accident and health
11 insurance and a managed care plan, as defined in Section 356r
12 of this Code, that is amended, delivered, issued, or renewed
13 after the effective date of this amendatory Act of 1997 shall
14 provide coverage for outpatient self-management training and
15 education, equipment, and supplies for the treatment of
16 insulin-dependent diabetes, insulin-using diabetes,
17 gestational diabetes, and non-insulin using diabetes.
18 (b) As used in this Section, "diabetes self-management
19 training" means instruction in an inpatient or outpatient
20 setting which enables diabetic patients to understand the
21 diabetic management process and daily management of diabetic
22 therapy as a means of avoiding frequent hospitalizations and
23 complications. Diabetes self-management training shall
24 include, but shall not be limited to, medical nutrition
25 therapy. For the purposes of this Section, "medical
26 nutrition therapy" shall have the meaning ascribed to
27 "medical nutrition care" under the Dietetic and Nutrition
28 Services Practice Act.
29 (c) Diabetes self-management training shall be provided
30 by a certified, registered, or licensed health care
31 professional with expertise in diabetes management.
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1 (d) Coverage under this Section for diabetes
2 self-management training, including, but not limited to,
3 medical nutrition therapy, shall be limited to the following:
4 (1) visits medically necessary upon the diagnosis
5 of diabetes by a physician;
6 (2) a physician diagnosis that represents a
7 significant change in the patient's symptoms or condition
8 requiring medically necessary changes in the patient's
9 self-management; and
10 (3) visits when reeducation or refresher training
11 is medically necessary.
12 The following equipment, supplies, and related services
13 shall be covered:
14 (1) blood glucose monitors;
15 (2) blood glucose monitors for the legally blind;
16 (3) cartridges for the legally blind;
17 (4) glucose tablets, glucagon emergency kits, and
18 injectable glucose;
19 (5) injection aids;
20 (6) insulin;
21 (7) insulin infusion devices;
22 (8) insulin pumps and appurtenances;
23 (9) oral agents for controlling blood sugar;
24 (10) podiatric appliances for prevention of
25 complications associated with diabetes;
26 (11) syringes, pen needles, lancets, and lancing
27 devices;
28 (12) test strips for glucose monitors; and
29 (13) visual reading and urine testing strips.
30 The Department of Insurance and the Department of Public
31 Health shall jointly develop, promulgate, and annually update
32 by rule a list of diabetic equipment and supplies for which
33 coverage shall be available under this Section. Covered
34 equipment and supplies must have been approved by the federal
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1 Food and Drug Administration.
2 Diabetes self-management training may be provided as part
3 of an office visit, group setting, or in-home visit.
4 Coverage under this Section shall be subject to the same
5 deductible and coinsurance provisions that apply to other
6 coverage under the policy.
7 (e) Other coverage under a policy or plan may not be
8 reduced or eliminated because of the requirements of this
9 Section. The Department shall issue rules necessary to
10 enforce the provisions of this Section.
11 (f) This Section does not restrict or prohibit any
12 person licensed in this State under any other Act from
13 engaging in the practice for which that person is licensed.
14 (215 ILCS 5/370s new)
15 Sec. 370s. Diabetes management training. All insurers
16 and administrators are subject to Section 356t of this Code.
17 (215 ILCS 5/511.114 new)
18 Sec. 511.114. Diabetes management training. All
19 administrators are subject to Section 356t of this Code.
20 Section 10. The Health Maintenance Organization Act is
21 amended by changing Section 5-3 as follows:
22 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
23 Sec. 5-3. Insurance Code provisions.
24 (a) Health Maintenance Organizations shall be subject to
25 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
26 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
27 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401,
28 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
29 subsection (2) of Section 367, and Articles VIII 1/2, XII,
30 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
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1 Code.
2 (b) For purposes of the Illinois Insurance Code, except
3 for Articles XIII and XIII 1/2, Health Maintenance
4 Organizations in the following categories are deemed to be
5 "domestic companies":
6 (1) a corporation authorized under the Medical
7 Service Plan Act, the Dental Service Plan Act, the Vision
8 Service Plan Act, the Pharmaceutical Service Plan Act,
9 the Voluntary Health Services Plan Act, or the Nonprofit
10 Health Care Service Plan Act;
11 (2) a corporation organized under the laws of this
12 State; or
13 (3) a corporation organized under the laws of
14 another state, 30% or more of the enrollees of which are
15 residents of this State, except a corporation subject to
16 substantially the same requirements in its state of
17 organization as is a "domestic company" under Article
18 VIII 1/2 of the Illinois Insurance Code.
19 (c) In considering the merger, consolidation, or other
20 acquisition of control of a Health Maintenance Organization
21 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
22 (1) the Director shall give primary consideration
23 to the continuation of benefits to enrollees and the
24 financial conditions of the acquired Health Maintenance
25 Organization after the merger, consolidation, or other
26 acquisition of control takes effect;
27 (2)(i) the criteria specified in subsection (1)(b)
28 of Section 131.8 of the Illinois Insurance Code shall not
29 apply and (ii) the Director, in making his determination
30 with respect to the merger, consolidation, or other
31 acquisition of control, need not take into account the
32 effect on competition of the merger, consolidation, or
33 other acquisition of control;
34 (3) the Director shall have the power to require
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1 the following information:
2 (A) certification by an independent actuary of
3 the adequacy of the reserves of the Health
4 Maintenance Organization sought to be acquired;
5 (B) pro forma financial statements reflecting
6 the combined balance sheets of the acquiring company
7 and the Health Maintenance Organization sought to be
8 acquired as of the end of the preceding year and as
9 of a date 90 days prior to the acquisition, as well
10 as pro forma financial statements reflecting
11 projected combined operation for a period of 2
12 years;
13 (C) a pro forma business plan detailing an
14 acquiring party's plans with respect to the
15 operation of the Health Maintenance Organization
16 sought to be acquired for a period of not less than
17 3 years; and
18 (D) such other information as the Director
19 shall require.
20 (d) The provisions of Article VIII 1/2 of the Illinois
21 Insurance Code and this Section 5-3 shall apply to the sale
22 by any health maintenance organization of greater than 10% of
23 its enrollee population (including without limitation the
24 health maintenance organization's right, title, and interest
25 in and to its health care certificates).
26 (e) In considering any management contract or service
27 agreement subject to Section 141.1 of the Illinois Insurance
28 Code, the Director (i) shall, in addition to the criteria
29 specified in Section 141.2 of the Illinois Insurance Code,
30 take into account the effect of the management contract or
31 service agreement on the continuation of benefits to
32 enrollees and the financial condition of the health
33 maintenance organization to be managed or serviced, and (ii)
34 need not take into account the effect of the management
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1 contract or service agreement on competition.
2 (f) Except for small employer groups as defined in the
3 Small Employer Rating, Renewability and Portability Health
4 Insurance Act and except for medicare supplement policies as
5 defined in Section 363 of the Illinois Insurance Code, a
6 Health Maintenance Organization may by contract agree with a
7 group or other enrollment unit to effect refunds or charge
8 additional premiums under the following terms and conditions:
9 (i) the amount of, and other terms and conditions
10 with respect to, the refund or additional premium are set
11 forth in the group or enrollment unit contract agreed in
12 advance of the period for which a refund is to be paid or
13 additional premium is to be charged (which period shall
14 not be less than one year); and
15 (ii) the amount of the refund or additional premium
16 shall not exceed 20% of the Health Maintenance
17 Organization's profitable or unprofitable experience with
18 respect to the group or other enrollment unit for the
19 period (and, for purposes of a refund or additional
20 premium, the profitable or unprofitable experience shall
21 be calculated taking into account a pro rata share of the
22 Health Maintenance Organization's administrative and
23 marketing expenses, but shall not include any refund to
24 be made or additional premium to be paid pursuant to this
25 subsection (f)). The Health Maintenance Organization and
26 the group or enrollment unit may agree that the
27 profitable or unprofitable experience may be calculated
28 taking into account the refund period and the immediately
29 preceding 2 plan years.
30 The Health Maintenance Organization shall include a
31 statement in the evidence of coverage issued to each enrollee
32 describing the possibility of a refund or additional premium,
33 and upon request of any group or enrollment unit, provide to
34 the group or enrollment unit a description of the method used
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1 to calculate (1) the Health Maintenance Organization's
2 profitable experience with respect to the group or enrollment
3 unit and the resulting refund to the group or enrollment unit
4 or (2) the Health Maintenance Organization's unprofitable
5 experience with respect to the group or enrollment unit and
6 the resulting additional premium to be paid by the group or
7 enrollment unit.
8 In no event shall the Illinois Health Maintenance
9 Organization Guaranty Association be liable to pay any
10 contractual obligation of an insolvent organization to pay
11 any refund authorized under this Section.
12 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
13 Section 15. The Limited Health Service Organization Act
14 is amended by changing Section 3009 as follows:
15 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
16 Sec. 3009. Point-of-service limited health service
17 contracts.
18 (a) An LHSO that offers a POS contract:
19 (1) shall include as in-plan covered services all
20 services required by law to be provided by an LHSO;
21 (2) shall provide incentives, which shall include
22 financial incentives, for enrollees to use in-plan
23 covered services;
24 (3) shall not offer services out-of-plan without
25 providing those services on an in-plan basis;
26 (4) may limit or exclude specific types of services
27 from coverage when obtained out-of-plan;
28 (5) may include annual out-of-pocket limits and
29 lifetime maximum benefits allowances for out-of-plan
30 services that are separate from any limits or allowances
31 applied to in-plan services;
32 (6) shall include an annual maximum benefit
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1 allowance not to exceed $2,500 per year that is separate
2 from any limits or allowances applied to in-plan
3 services;
4 (7) may limit the groups to which a POS product is
5 offered, however, if a POS product is offered to a group,
6 then it must be offered to all eligible members of that
7 group, when an LHSO provider is available;
8 (8) shall not consider emergency services,
9 authorized referral services, or non-routine services
10 obtained out of the service area to be POS services; and
11 (9) may treat as out-of-plan services those
12 services that an enrollee obtains from a participating
13 provider, but for which the proper authorization was not
14 given by the LHSO.
15 (b) An LHSO offering a POS contract shall be subject to
16 the following limitations:
17 (1) The LHSO shall not expend in any calendar
18 quarter more than 20% of its total limited health
19 services expenditures for all its members for out-of-plan
20 covered services.
21 (2) If the amount specified in paragraph (1) is
22 exceeded by 2% in a quarter, the LHSO shall effect
23 compliance with paragraph (1) by the end of the following
24 quarter.
25 (3) If compliance with the amount specified in
26 paragraph (1) is not demonstrated in the LHSO's next
27 quarterly report, the LHSO may not offer the POS contract
28 to new groups or include the POS option in the renewal of
29 an existing group until compliance with the amount
30 specified in paragraph (1) is demonstrated or otherwise
31 allowed by the Director.
32 (4) Any LHSO failing, without just cause, to comply
33 with the provisions of this subsection shall be required,
34 after notice and hearing, to pay a penalty of $250 for
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1 each day out of compliance, to be recovered by the
2 Director of Insurance. Any penalty recovered shall be
3 paid into the General Revenue Fund. The Director may
4 reduce the penalty if the LHSO demonstrates to the
5 Director that the imposition of the penalty would
6 constitute a financial hardship to the LHSO.
7 (c) Any LHSO that offers a POS product shall:
8 (1) File a quarterly financial statement detailing
9 compliance with the requirements of subsection (b).
10 (2) Track out-of-plan POS utilization separately
11 from in-plan or non-POS out-of-plan emergency care,
12 referral care, and urgent care out of the service area
13 utilization.
14 (3) Record out-of-plan utilization in a manner that
15 will permit such utilization and cost reporting as the
16 Director may, by regulation, require.
17 (4) Demonstrate to the Director's satisfaction that
18 the LHSO has the fiscal, administrative, and marketing
19 capacity to control its POS enrollment, utilization, and
20 costs so as not to jeopardize the financial security of
21 the LHSO.
22 (5) Maintain the deposit required by subsection (b)
23 of Section 2006 in addition to any other deposit required
24 under this Act.
25 (d) An LHSO shall not issue a POS contract until it has
26 filed and had approved by the Director a plan to comply with
27 the provisions of this Section. The compliance plan shall at
28 a minimum include provisions demonstrating that the LHSO will
29 do all of the following:
30 (1) Design the benefit levels and conditions of
31 coverage for in-plan covered services and out-of-plan
32 covered services as required by this Article.
33 (2) Provide or arrange for the provision of
34 adequate systems to:
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1 (A) process and pay claims for all out-of-plan
2 covered services;
3 (B) meet the requirements for a POS contract
4 set forth in this Section and any additional
5 requirements that may be set forth by the Director;
6 and
7 (C) generate accurate data and financial and
8 regulatory reports on a timely basis so that the
9 Department can evaluate the LHSO's experience with
10 the POS contract and monitor compliance with POS
11 contract provisions.
12 (3) Comply initially and on an ongoing basis with
13 the requirements of subsections (b) and (c).
14 (e) A limited health service organization that offers a
15 POS contract must comply with Section 356t of the Illinois
16 Insurance Code.
17 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
18 Section 20. The Voluntary Health Services Plans Act is
19 amended by changing Section 10 as follows:
20 (215 ILCS 165/10) (from Ch. 32, par. 604)
21 Sec. 10. Application of Insurance Code provisions.
22 Health services plan corporations and all persons interested
23 therein or dealing therewith shall be subject to the
24 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
25 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
26 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
27 (15) of Section 367 of the Illinois Insurance Code.
28 (Source: P.A. 89-514, eff. 7-17-96.)
29 Section 99. Effective date. This Act takes effect upon
30 becoming law.