96TH GENERAL ASSEMBLY
State of Illinois
2009 and 2010
HB5407


 
Introduced 2/5/2010, by Rep. William Davis
 
SYNOPSIS AS INTRODUCED:
 		





 








215 ILCS 5/356w










     Amends the Illinois Insurance Code to include in the requirement for diabetes self-management training and education coverage,  coverage for the treatment of pain associated with complications of diabetes, including, but not limited to, diabetic peripheral neuropathy.
  















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A BILL FOR









 




  






HB5407

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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 
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changing Section 356w as follows:
 



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    (215 ILCS 5/356w)



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

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

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outpatient self-management
training and education, equipment, 
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and supplies, as set forth in this Section,
for the treatment 
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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 
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an outpatient setting
which enables a diabetic patient to 
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understand the diabetic management process
and daily 
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management of
diabetic therapy as a means of avoiding frequent 
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hospitalization and
complications.  Diabetes self-management 
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training shall include
the content areas listed in the National 
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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 
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Nutrition Services
Practice Act.

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

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


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

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

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    (c) Coverage under this Section for diabetes 
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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 
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    provider upon
initial diagnosis of diabetes
by the 
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    patient's
physician or, if diagnosis of diabetes was made 
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    within one year prior to the
effective date of
this 
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    amendatory Act
of 1998 where the insured was a covered 
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    individual, up to 3 medically necessary
visits to a 
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    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 
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    provider upon a
determination by a
patient's
physician that 
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    a significant change in the patient's symptoms or medical

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

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    Payment by the  insurer or health maintenance organization 
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for the coverage
required for diabetes self-management 
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training pursuant to the provisions of
this Section is only 
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required to be made for services provided.
No coverage is 
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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 
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to coverage
under
the policy for other
services provided by the 
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same type of provider.

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    (d) Coverage shall be provided for the following
equipment 
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when medically necessary
and prescribed by a physician licensed 
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to practice medicine in all
of its branches.
Coverage for the 
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following items shall be subject to deductible, co-payment
and 
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co-insurance provisions
provided for under the policy or a 
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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 
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accident and health
insurance that does not provide a durable 
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medical equipment benefit.

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


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        (5) glucagon emergency kits; and .

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        (6) the treatment of pain associated with 
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    complications of diabetes, including, but not limited to, 
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    diabetic peripheral neuropathy. 
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    This subsection does not apply to a group policy of 
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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 
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by a
physician or by a
physician to whom a physician has 
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referred the patient.  Coverage
for regular foot care exams

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shall be subject to the same deductible, co-payment, and 
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co-insurance
provisions
that apply under the policy for
other 
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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 
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setting, or home
visit.

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

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