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, as defined by
3the contract of insurance, that allow the patient to maintain
4an A1c level within the range identified in nationally
5recognized standards of care.
6    "Medical nutrition therapy" shall have the meaning
7ascribed to "medical nutrition care" in the Dietetic and
8Nutrition Services Practice Act.
9    "Physician" means a physician licensed to practice
10medicine in all of its branches providing care to the
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
3self-management training, including medical nutrition
4education, 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
24for the coverage required for diabetes self-management
25training pursuant to the provisions of this Section is only
26required to be made for services provided. No coverage is



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1required for additional visits beyond those specified in items
2(1) and (2) of this subsection.
3    Coverage under this subsection (c) for diabetes
4self-management training shall be subject to the same
5deductible, co-payment, and co-insurance provisions that apply
6to coverage under the policy for other services provided by the
7same type of provider.
8    (d) Coverage shall be provided for the following equipment
9when medically necessary and prescribed by a physician licensed
10to practice medicine in all of its branches. Coverage for the
11following items shall be subject to deductible, co-payment and
12co-insurance provisions provided for under the policy or a
13durable 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
19accident and health insurance that does not provide a durable
20medical equipment benefit.
21    (e) Coverage shall be provided for the following
22pharmaceuticals and supplies when medically necessary and
23prescribed by a physician licensed to practice medicine in all
24of its branches. Coverage for the following items shall be
25subject to the same coverage, deductible, co-payment, and
26co-insurance provisions under the policy or a drug rider to the



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2        (1) insulin;
3        (2) syringes and needles;
4        (3) test strips for glucose monitors;
5        (4) FDA approved oral agents used to control blood
6    sugar; and
7        (5) glucagon emergency kits.
8    This subsection does not apply to a group policy of
9accident and health insurance that does not provide a drug
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.)