Full Text of HB5653 98th General Assembly
HB5653 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 HB5653 Introduced , by Rep. Tom Cross - Cynthia Soto SYNOPSIS AS INTRODUCED: |
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Amends the Illinois Insurance Code in the provision concerning diabetes self-management training and education. With regard to the required coverage for test strips for glucose monitors, provides that insurers shall provide coverage for up to 10 strips per day for an individual diagnosed with type 1 diabetes or who is otherwise on intensive insulin therapy and that the strips shall be of the individual's choosing and not subject to any insurer pre-approval requirements.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 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 is | 10 | | amended,
delivered,
issued, or renewed after the
effective date | 11 | | of this amendatory Act of 1998 shall provide coverage for
| 12 | | outpatient self-management
training and education, equipment, | 13 | | and supplies, as set forth in this Section,
for the treatment | 14 | | of type 1 diabetes, type 2 diabetes, and gestational diabetes
| 15 | | 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 frequent | 21 | | hospitalization and
complications. Diabetes self-management | 22 | | training shall include
the content areas listed in the National | 23 | | Standards for Diabetes Self-Management
Education Programs as |
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| 1 | | published by the American Diabetes Association, including
| 2 | | medical nutrition therapy and education programs, as defined by | 3 | | the contract of insurance, that allow the patient to maintain | 4 | | an A1c level within the range identified in nationally | 5 | | recognized standards of care.
| 6 | | "Medical nutrition therapy" shall have the meaning
| 7 | | ascribed to that term in the Dietitian Nutritionist
Practice | 8 | | Act.
| 9 | | "Physician" means a
physician licensed to practice | 10 | | medicine in all of
its branches providing care to the | 11 | | individual.
| 12 | | "Qualified provider" for an
individual that is enrolled in:
| 13 | | (1) a health maintenance organization that uses a
| 14 | | primary
care physician to
control access to specialty care | 15 | | means (A) the individual's primary care
physician licensed | 16 | | to practice
medicine in all of its branches, (B) a | 17 | | physician licensed to practice
medicine in all of its | 18 | | branches to
whom the individual has been referred by the | 19 | | primary care physician, or (C) a
certified, registered, or
| 20 | | licensed network health care professional with expertise | 21 | | in diabetes management
to whom the individual
has been | 22 | | referred by the primary care physician.
| 23 | | (2) an insurance plan
means (A) a physician licensed to | 24 | | practice medicine in
all of its branches or (B) a
| 25 | | certified, registered, or licensed health care | 26 | | professional with expertise in
diabetes management to whom |
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| 1 | | the individual has been referred by a physician.
| 2 | | (c) Coverage under this Section for diabetes | 3 | | self-management training,
including medical nutrition
| 4 | | education, shall be limited to the following:
| 5 | | (1) Up to 3 medically necessary visits to a qualified | 6 | | provider upon
initial diagnosis of diabetes
by the | 7 | | patient's
physician or, if diagnosis of diabetes was made | 8 | | within one year prior to the
effective date of
this | 9 | | amendatory Act
of 1998 where the insured was a covered | 10 | | individual, up to 3 medically necessary
visits to a | 11 | | qualified provider within one
year after that
effective
| 12 | | date.
| 13 | | (2) Up to 2 medically necessary visits to a qualified | 14 | | provider upon a
determination by a
patient's
physician that | 15 | | a significant change in the patient's symptoms or medical
| 16 | | condition has
occurred. A "significant change" in | 17 | | condition means symptomatic
hyperglycemia (greater than | 18 | | 250 mg/dl on repeated occasions), severe
hypoglycemia | 19 | | (requiring the assistance of another person), onset or | 20 | | progression
of diabetes, or a significant change in medical | 21 | | condition that would require a
significantly different | 22 | | treatment regimen.
| 23 | | Payment by the insurer or health maintenance organization | 24 | | for the coverage
required for diabetes self-management | 25 | | training pursuant to the provisions of
this Section is only | 26 | | required to be made for services provided.
No coverage is |
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| 1 | | required for additional visits beyond those specified in items
| 2 | | (1) and (2) of this subsection.
| 3 | | Coverage under this subsection (c) for diabetes | 4 | | self-management training
shall
be subject to the same
| 5 | | deductible, co-payment, and co-insurance provisions that apply | 6 | | to coverage
under
the policy for other
services provided by the | 7 | | same type of provider.
| 8 | | (d) Coverage shall be provided for the following
equipment | 9 | | when medically necessary
and prescribed by a physician licensed | 10 | | to practice medicine in all
of its branches.
Coverage for the | 11 | | following items shall be subject to deductible, co-payment
and | 12 | | co-insurance provisions
provided for under the policy or a | 13 | | durable medical equipment rider to the
policy:
| 14 | | (1) blood glucose monitors;
| 15 | | (2) blood glucose monitors for the legally blind;
| 16 | | (3) cartridges for the legally blind; and
| 17 | | (4) lancets and lancing devices.
| 18 | | This subsection does not apply to a group policy of | 19 | | accident and health
insurance that does not provide a durable | 20 | | medical equipment benefit.
| 21 | | (e) Coverage shall be provided for the following | 22 | | pharmaceuticals and
supplies when
medically necessary and | 23 | | prescribed by a physician licensed to
practice medicine in all | 24 | | of its
branches.
Coverage for the following items shall be | 25 | | subject to the same coverage,
deductible,
co-payment, and | 26 | | co-insurance
provisions under the policy or a drug rider to the |
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| 1 | | policy:
| 2 | | (1) insulin;
| 3 | | (2) syringes and needles;
| 4 | | (3) test strips for glucose monitors (insurers shall | 5 | | provide coverage for up to 10 strips per day for an | 6 | | individual diagnosed with type 1 diabetes or who is | 7 | | otherwise on intensive insulin therapy; the strips shall be | 8 | | of the individual's choosing and not subject to any insurer | 9 | | pre-approval requirements) ;
| 10 | | (4) FDA approved oral agents used to control blood | 11 | | sugar; and
| 12 | | (5) glucagon emergency kits.
| 13 | | This subsection does not apply to a group policy of | 14 | | accident and health
insurance that does not provide a drug | 15 | | benefit.
| 16 | | (f) Coverage shall be provided for regular foot care exams | 17 | | by a
physician or by a
physician to whom a physician has | 18 | | referred the patient. Coverage
for regular foot care exams
| 19 | | shall be subject to the same deductible, co-payment, and | 20 | | co-insurance
provisions
that apply under the policy for
other | 21 | | services provided by the same type of provider.
| 22 | | (g) If authorized by a physician, diabetes self-management
| 23 | | training may be provided as a part of an office visit, group | 24 | | setting, or home
visit.
| 25 | | (h) This Section shall not apply to agreements, contracts, | 26 | | or policies that
provide coverage for a specified diagnosis or |
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| 1 | | other limited benefit coverage.
| 2 | | (Source: P.A. 97-281, eff. 1-1-12; 97-1141, eff. 12-28-12.)
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