97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
SB1942

 

Introduced 2/10/2011, by Sen. William Delgado

 

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

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356w as follows:
 
6    (215 ILCS 5/356w)
7    Sec. 356w. Diabetes self-management training and
8education.
9    (a) A group policy of accident and health insurance that is
10amended, delivered, issued, or renewed after the effective date
11of this amendatory Act of 1998 shall provide coverage for
12outpatient self-management training and education, equipment,
13and supplies, as set forth in this Section, for the treatment
14of type 1 diabetes, type 2 diabetes, and gestational diabetes
15mellitus.
16    (b) As used in this Section:
17    "Diabetes self-management training" means instruction in
18an outpatient setting which enables a diabetic patient to
19understand the diabetic management process and daily
20management of diabetic therapy as a means of avoiding frequent
21hospitalization and complications. Diabetes self-management
22training shall include the content areas listed in the National
23Standards for Diabetes Self-Management Education Programs as

 

 

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1published by the American Diabetes Association, including
2medical nutrition therapy.
3    "Medical nutrition therapy" shall have the meaning
4ascribed to "medical nutrition care" in the Dietetic and
5Nutrition Services Practice Act.
6    "Physician" means a physician licensed to practice
7medicine in all of its branches providing care to the
8individual.
9    "Qualified provider" for an individual that is enrolled in:
10        (1) a health maintenance organization that uses a
11    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
17    licensed network health care professional with expertise
18    in diabetes management to whom the individual has been
19    referred by the primary care physician.
20        (2) an insurance plan means (A) a physician licensed to
21    practice medicine in all of its branches or (B) a
22    certified, registered, or licensed health care
23    professional with expertise in diabetes management to whom
24    the individual has been referred by a physician.
25    (c) Coverage under this Section for diabetes
26self-management training, including medical nutrition

 

 

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1education, shall be limited to the following:
2        (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
9    date.
10        (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
13    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.
20    Payment by the insurer or health maintenance organization
21for the coverage required for diabetes self-management
22training pursuant to the provisions of this Section is only
23required to be made for services provided. No coverage is
24required for additional visits beyond those specified in items
25(1) and (2) of this subsection.
26    Coverage under this subsection (c) for diabetes

 

 

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1self-management training shall be subject to the same
2deductible, co-payment, and co-insurance provisions that apply
3to coverage under the policy for other services provided by the
4same type of provider.
5    (d) Coverage shall be provided for the following equipment
6when medically necessary and prescribed by a physician licensed
7to practice medicine in all of its branches. Coverage for the
8following items shall be subject to deductible, co-payment and
9co-insurance provisions provided for under the policy or a
10durable medical equipment rider to the policy:
11        (1) blood glucose monitors;
12        (2) blood glucose monitors for the legally blind;
13        (3) cartridges for the legally blind; and
14        (4) lancets and lancing devices.
15    This subsection does not apply to a group policy of
16accident and health insurance that does not provide a durable
17medical equipment benefit.
18    (e) Coverage shall be provided for the following
19pharmaceuticals and supplies when medically necessary and
20prescribed by a physician licensed to practice medicine in all
21of its branches. Coverage for the following items shall be
22subject to the same coverage, deductible, co-payment, and
23co-insurance provisions under the policy or a drug rider to the
24policy:
25        (1) insulin;
26        (2) syringes and needles;

 

 

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1        (3) test strips for glucose monitors;
2        (4) FDA approved oral agents used to control blood
3    sugar; and
4        (5) glucagon emergency kits; and .
5        (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
9accident and health insurance that does not provide a drug
10benefit.
11    (f) Coverage shall be provided for regular foot care exams
12by a physician or by a physician to whom a physician has
13referred the patient. Coverage for regular foot care exams
14shall be subject to the same deductible, co-payment, and
15co-insurance provisions that apply under the policy for other
16services provided by the same type of provider.
17    (g) If authorized by a physician, diabetes self-management
18training may be provided as a part of an office visit, group
19setting, or home visit.
20    (h) This Section shall not apply to agreements, contracts,
21or policies that provide coverage for a specified diagnosis or
22other limited benefit coverage.
23(Source: P.A. 90-741, eff. 1-1-99.)