Public Act 097-0281
 
HB2249 EnrolledLRB097 08144 RPM 48267 b



    AN ACT concerning regulation.

 
    Be it enacted by the People of the State of Illinois, 
represented in the General Assembly: 



 
    Section 5. The Illinois Insurance Code is amended  by 
changing Section 356w as follows:
 



    (215 ILCS 5/356w)



    Sec. 356w. Diabetes self-management training and 
education. 

    (a) A group policy of accident and health insurance that is 
amended,
delivered,
issued, or renewed after the
effective date 
of this amendatory Act of 1998 shall provide coverage for

outpatient self-management
training and education, equipment, 
and supplies, as set forth in this Section,
for the treatment 
of type 1 diabetes, type 2 diabetes, and gestational diabetes

mellitus.

    (b) As used in this Section:

    "Diabetes self-management training"
means instruction in 
an outpatient setting
which enables a diabetic patient to 
understand the diabetic management process
and daily 
management of
diabetic therapy as a means of avoiding frequent 
hospitalization and
complications.  Diabetes self-management 
training shall include
the content areas listed in the National 
Standards for Diabetes Self-Management
Education Programs as 
published by the American Diabetes Association, including

medical nutrition therapy and education programs, as defined by 
the contract of insurance, that allow the patient to maintain 
an A1c level within the range identified in nationally 
recognized standards of care.

    "Medical nutrition therapy" shall have the meaning

ascribed to "medical nutrition care" in the Dietetic and 
Nutrition Services
Practice Act.

    "Physician" means a
physician licensed to practice 
medicine in all of
its branches providing care to the 
individual.

    "Qualified provider" for an
individual that is enrolled in:


        (1) a health maintenance organization that uses a

    primary
care physician to
control access to specialty care 
    means (A) the individual's primary care
physician licensed 
    to practice
medicine in all of its branches, (B) a 
    physician licensed to practice
medicine in all of its 
    branches to
whom the individual has been referred by the 
    primary care physician, or (C) a
certified, registered, or

    licensed network health care professional with expertise 
    in diabetes management
to whom the individual
has been 
    referred by the primary care physician.


        (2) an insurance plan
means (A) a physician licensed to 
    practice medicine in
all of its branches or (B) a

    certified, registered, or licensed health care 
    professional with expertise in
diabetes management to whom 
    the individual has been referred by a physician.

    (c) Coverage under this Section for diabetes 
self-management training,
including medical nutrition

education, shall be limited to the following:


        (1) Up to 3 medically necessary visits to a qualified 
    provider upon
initial diagnosis of diabetes
by the 
    patient's
physician or, if diagnosis of diabetes was made 
    within one year prior to the
effective date of
this 
    amendatory Act
of 1998 where the insured was a covered 
    individual, up to 3 medically necessary
visits to a 
    qualified provider within one
year after that
effective

    date.


        (2) Up to 2 medically necessary visits to a qualified 
    provider upon a
determination by a
patient's
physician that 
    a significant change in the patient's symptoms or medical

    condition has
occurred.  A "significant change" in 
    condition means symptomatic
hyperglycemia (greater than 
    250 mg/dl on repeated occasions), severe
hypoglycemia 
    (requiring the assistance of another person), onset or 
    progression
of diabetes, or a significant change in medical 
    condition that would require a
significantly different 
    treatment regimen.

    Payment by the  insurer or health maintenance organization 
for the coverage
required for diabetes self-management 
training pursuant to the provisions of
this Section is only 
required to be made for services provided.
No coverage is 
required for additional visits beyond those specified in items

(1) and (2) of this subsection.

    Coverage under this subsection (c) for diabetes 
self-management training
shall
be subject to the same

deductible, co-payment, and co-insurance provisions that apply 
to coverage
under
the policy for other
services provided by the 
same type of provider.

    (d) Coverage shall be provided for the following
equipment 
when medically necessary
and prescribed by a physician licensed 
to practice medicine in all
of its branches.
Coverage for the 
following items shall be subject to deductible, co-payment
and 
co-insurance provisions
provided for under the policy or a 
durable medical equipment rider to the
policy:


        (1) blood glucose monitors;


        (2) blood glucose monitors for the legally blind;


        (3) cartridges for the legally blind; and


        (4) lancets and lancing devices.

    This subsection does not apply to a group policy of 
accident and health
insurance that does not provide a durable 
medical equipment benefit.

    (e) Coverage shall be provided for the following 
pharmaceuticals and
supplies when
medically necessary and 
prescribed by a physician licensed to
practice medicine in all 
of its
branches.
Coverage for the following items shall be 
subject to the same coverage,
deductible,
co-payment, and 
co-insurance
provisions under the policy or a drug rider to the 
policy:


        (1) insulin;


        (2) syringes and needles;


        (3) test strips for glucose monitors;


        (4) FDA approved oral agents used to control blood 
    sugar; and


        (5) glucagon emergency kits.

    This subsection does not apply to a group policy of 
accident and health
insurance that does not provide a drug 
benefit.

    (f) Coverage shall be provided for regular foot care exams 
by a
physician or by a
physician to whom a physician has 
referred the patient.  Coverage
for regular foot care exams

shall be subject to the same deductible, co-payment, and 
co-insurance
provisions
that apply under the policy for
other 
services provided by the same type of provider.

    (g) If authorized by a physician, diabetes self-management

training may be provided as a part of an office visit, group 
setting, or home
visit.

    (h) This Section shall not apply to agreements, contracts, 
or policies that
provide coverage for a specified diagnosis or 
other limited benefit coverage.

(Source: P.A. 90-741, eff. 1-1-99.)