Illinois General Assembly - Full Text of HB2249
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Full Text of HB2249  97th General Assembly



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1    AN ACT concerning regulation.
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
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
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 and education programs that allow the
3patient to maintain an A1c level within the range identified in
4nationally recognized standards of care.
5    "Medical nutrition therapy" shall have the meaning
6ascribed to "medical nutrition care" in the Dietetic and
7Nutrition Services Practice Act.
8    "Physician" means a physician licensed to practice
9medicine in all of its branches providing care to the
11    "Qualified provider" for an individual that is enrolled in:
12        (1) a health maintenance organization that uses a
13    primary care physician to control access to specialty care
14    means (A) the individual's primary care physician licensed
15    to practice medicine in all of its branches, (B) a
16    physician licensed to practice medicine in all of its
17    branches to whom the individual has been referred by the
18    primary care physician, or (C) a certified, registered, or
19    licensed network health care professional with expertise
20    in diabetes management to whom the individual has been
21    referred by the primary care physician.
22        (2) an insurance plan means (A) a physician licensed to
23    practice medicine in all of its branches or (B) a
24    certified, registered, or licensed health care
25    professional with expertise in diabetes management to whom
26    the individual has been referred by a physician.



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1    (c) Coverage under this Section for diabetes
2self-management training, including medical nutrition
3education, shall be limited to the following:
4        (1) Up to 3 medically necessary visits to a qualified
5    provider upon initial diagnosis of diabetes by the
6    patient's physician or, if diagnosis of diabetes was made
7    within one year prior to the effective date of this
8    amendatory Act of 1998 where the insured was a covered
9    individual, up to 3 medically necessary visits to a
10    qualified provider within one year after that effective
11    date.
12        (2) Up to 2 medically necessary visits to a qualified
13    provider upon a determination by a patient's physician that
14    a significant change in the patient's symptoms or medical
15    condition has occurred. A "significant change" in
16    condition means symptomatic hyperglycemia (greater than
17    250 mg/dl on repeated occasions), severe hypoglycemia
18    (requiring the assistance of another person), onset or
19    progression of diabetes, or a significant change in medical
20    condition that would require a significantly different
21    treatment regimen.
22    Payment by the insurer or health maintenance organization
23for the coverage required for diabetes self-management
24training pursuant to the provisions of this Section is only
25required to be made for services provided. No coverage is
26required for additional visits beyond those specified in items



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



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1        (1) insulin;
2        (2) syringes and needles;
3        (3) test strips for glucose monitors;
4        (4) FDA approved oral agents used to control blood
5    sugar; and
6        (5) glucagon emergency kits.
7    This subsection does not apply to a group policy of
8accident and health insurance that does not provide a drug
10    (f) Coverage shall be provided for regular foot care exams
11by a physician or by a physician to whom a physician has
12referred the patient. Coverage for regular foot care exams
13shall be subject to the same deductible, co-payment, and
14co-insurance provisions that apply under the policy for other
15services provided by the same type of provider.
16    (g) If authorized by a physician, diabetes self-management
17training may be provided as a part of an office visit, group
18setting, or home visit.
19    (h) This Section shall not apply to agreements, contracts,
20or policies that provide coverage for a specified diagnosis or
21other limited benefit coverage.
22(Source: P.A. 90-741, eff. 1-1-99.)