Public Act 103-0512
 
SB2195 EnrolledLRB103 28476 BMS 54857 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 356z.18 as follows:
 
    (215 ILCS 5/356z.18)
    Sec. 356z.18. Prosthetic and customized orthotic devices.
    (a) For the purposes of this Section:
    "Customized orthotic device" means a supportive device for 
the body or a part of the body, the head, neck, or extremities, 
and includes the replacement or repair of the device based on 
the patient's physical condition as medically necessary, 
excluding foot orthotics defined as an in-shoe device designed 
to support the structural components of the foot during 
weight-bearing activities.
    "Licensed provider" means a prosthetist, orthotist, or 
pedorthist licensed to practice in this State.
    "Prosthetic device" means an artificial device to replace, 
in whole or in part, an arm or leg and includes accessories 
essential to the effective use of the device and the 
replacement or repair of the device based on the patient's 
physical condition as medically necessary.
    (b) This amendatory Act of the 96th General Assembly shall 
provide benefits to any person covered thereunder for expenses 
incurred in obtaining a prosthetic or custom orthotic device 
from any Illinois licensed prosthetist, licensed orthotist, or 
licensed pedorthist as required under the Orthotics, 
Prosthetics, and Pedorthics Practice Act. 
    (c) A group or individual major medical policy of accident 
or health insurance or managed care plan or medical, health, 
or hospital service corporation contract that provides 
coverage for prosthetic or custom orthotic care and is  
amended, delivered, issued, or renewed 6 months after the 
effective date of this amendatory Act of the 96th General 
Assembly must provide coverage for prosthetic and orthotic 
devices in accordance with this subsection (c). The coverage 
required under this Section shall be subject to the other 
general exclusions, limitations, and financial requirements of 
the policy, including coordination of benefits, participating 
provider requirements, utilization review of health care 
services, including review of medical necessity, case 
management, and experimental and investigational treatments, 
and other managed care provisions under terms and conditions 
that are no less favorable than the terms and conditions that 
apply to substantially all medical and surgical benefits 
provided under the plan or coverage.
    (d) With respect to an enrollee at any age, in addition to 
coverage of a prosthetic or custom orthotic device required by 
this Section, benefits shall be provided for a prosthetic or 
custom orthotic device determined by the enrollee's provider 
to be the most appropriate model that is medically necessary 
for the enrollee to perform physical activities, as 
applicable, such as running, biking, swimming, and lifting 
weights, and to maximize the enrollee's whole body health and 
strengthen the  lower and upper  limb function.
    (e) The requirements of this Section do not constitute an 
addition to this State's essential health benefits that 
requires defrayal of costs by this State pursuant to 42 U.S.C.  
18031(d)(3)(B). 
    (f) (d) The policy or plan or contract may require prior 
authorization for the prosthetic or orthotic devices in the 
same manner that prior authorization is required for any other 
covered benefit. 
    (g) (e) Repairs and replacements of prosthetic and 
orthotic devices are also covered, subject to the co-payments 
and deductibles, unless necessitated by misuse or loss. 
    (h) (f) A policy or plan or contract may require that, if 
coverage is provided through a managed care plan, the benefits 
mandated pursuant to this Section shall be covered benefits 
only if the prosthetic or orthotic devices are provided by a 
licensed provider employed by a provider service who contracts 
with or is designated by the carrier, to the extent that the 
carrier provides in-network and out-of-network service, the 
coverage for the prosthetic or orthotic device shall be 
offered no less extensively.
    (i) (g) The policy or plan or contract shall also meet 
adequacy requirements as established by the Health Care 
Reimbursement Reform Act of 1985 of the Illinois Insurance 
Code. 
    (j) (h) This Section shall not apply to accident only, 
specified disease, short-term hospital or medical, hospital 
confinement indemnity, credit, dental, vision, Medicare 
supplement, long-term care, basic hospital and 
medical-surgical expense coverage, disability income insurance 
coverage, coverage issued as a supplement to liability 
insurance, workers' compensation insurance, or automobile 
medical payment insurance. 

(Source: P.A. 96-833, eff. 6-1-10.)
  
 
    Section 99. Effective date. This Act takes effect January 
1, 2025.


Effective Date:  1/1/2025