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92_HB3567
LRB9208337JSpc
1 AN ACT concerning insurance.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356w as follows:
6 (215 ILCS 5/356w)
7 Sec. 356w. Diabetes self-management training and
8 education.
9 (a) A group policy of accident and health insurance that
10 is amended, delivered, issued, or renewed after the effective
11 date of this amendatory Act of 1998 shall provide coverage
12 for outpatient self-management training and education,
13 equipment, and supplies, as set forth in this Section, for
14 the treatment of type 1 diabetes, type 2 diabetes, and
15 gestational diabetes mellitus.
16 (b) As used in this Section:
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
21 frequent hospitalization and complications. Diabetes
22 self-management training shall include the content areas
23 listed in the National Standards for Diabetes Self-Management
24 Education Programs as published by the American Diabetes
25 Association, including medical nutrition therapy.
26 "Medical nutrition therapy" shall have the meaning
27 ascribed to "medical nutrition care" in the Dietetic and
28 Nutrition Services Practice Act.
29 "Physician" means a physician licensed to practice
30 medicine in all of its branches providing care to the
31 individual.
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1 "Qualified provider" for an individual that is enrolled
2 in:
3 (1) a health maintenance organization that uses a
4 primary care physician to control access to specialty
5 care means (A) the individual's primary care physician
6 licensed to practice medicine in all of its branches, (B)
7 a physician licensed to practice medicine in all of its
8 branches to whom the individual has been referred by the
9 primary care physician, or (C) a certified, registered,
10 or licensed network health care professional with
11 expertise in diabetes management to whom the individual
12 has been referred by the primary care physician.
13 (2) an insurance plan means (A) a physician
14 licensed to practice medicine in all of its branches or
15 (B) a certified, registered, or licensed health care
16 professional with expertise in diabetes management to
17 whom the individual has been referred by a physician.
18 (c) Coverage under this Section for diabetes
19 self-management training, including medical nutrition
20 education, shall be limited to the following:
21 (1) Up to 3 medically necessary visits to a
22 qualified provider upon initial diagnosis of diabetes by
23 the patient's physician or, if diagnosis of diabetes was
24 made within one year prior to the effective date of this
25 amendatory Act of 1998 where the insured was a covered
26 individual, up to 3 medically necessary visits to a
27 qualified provider within one year after that effective
28 date.
29 (2) Up to 2 medically necessary visits to a
30 qualified provider upon a determination by a patient's
31 physician that a significant change in the patient's
32 symptoms or medical condition has occurred. A
33 "significant change" in condition means symptomatic
34 hyperglycemia (greater than 250 mg/dl on repeated
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1 occasions), severe hypoglycemia (requiring the assistance
2 of another person), onset or progression of diabetes, or
3 a significant change in medical condition that would
4 require a significantly different treatment regimen.
5 Payment by the insurer or health maintenance
6 organization for the coverage required for diabetes
7 self-management training pursuant to the provisions of this
8 Section is only required to be made for services provided. No
9 coverage is required for additional visits beyond those
10 specified in items (1) and (2) of this subsection.
11 Coverage under this subsection (c) for diabetes
12 self-management training shall be subject to the same
13 deductible, co-payment, and co-insurance provisions that
14 apply to coverage under the policy for other services
15 provided by the same type of provider.
16 (d) Coverage shall be provided for the following
17 equipment when medically necessary and prescribed by a
18 physician licensed to practice medicine in all of its
19 branches. Coverage for the following items shall be subject
20 to deductible, co-payment and co-insurance provisions
21 provided for under the policy or a durable medical equipment
22 rider to the policy:
23 (1) blood glucose monitors;
24 (2) blood glucose monitors for the legally blind;
25 (3) cartridges for the legally blind; and
26 (4) lancets and lancing devices; and.
27 (5) insulin pumps.
28 This subsection does not apply to a group policy of
29 accident and health insurance that does not provide a durable
30 medical equipment benefit.
31 (e) Coverage shall be provided for the following
32 pharmaceuticals and supplies when medically necessary and
33 prescribed by a physician licensed to practice medicine in
34 all of its branches. Coverage for the following items shall
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1 be subject to the same coverage, deductible, co-payment, and
2 co-insurance provisions under the policy or a drug rider to
3 the policy:
4 (1) insulin;
5 (2) syringes and needles;
6 (3) test strips for glucose monitors;
7 (4) FDA approved oral agents used to control blood
8 sugar; and
9 (5) glucagon emergency kits.
10 This subsection does not apply to a group policy of
11 accident and health insurance that does not provide a drug
12 benefit.
13 (f) Coverage shall be provided for regular foot care
14 exams by a physician or by a physician to whom a physician
15 has referred the patient. Coverage for regular foot care
16 exams shall be subject to the same deductible, co-payment,
17 and co-insurance provisions that apply under the policy for
18 other services provided by the same type of provider.
19 (g) If authorized by a physician, diabetes
20 self-management training may be provided as a part of an
21 office visit, group setting, or home visit.
22 (h) This Section shall not apply to agreements,
23 contracts, or policies that provide coverage for a specified
24 diagnosis or other limited benefit coverage.
25 (Source: P.A. 90-741, eff. 1-1-99.)