Full Text of SB2195 103rd General Assembly
SB2195enr 103RD GENERAL ASSEMBLY |
| | SB2195 Enrolled | | LRB103 28476 BMS 54857 b |
|
| 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 356z.18 as follows: | 6 | | (215 ILCS 5/356z.18) | 7 | | Sec. 356z.18. Prosthetic and customized orthotic devices. | 8 | | (a) For the purposes of this Section: | 9 | | "Customized orthotic device" means a supportive device for | 10 | | the body or a part of the body, the head, neck, or extremities, | 11 | | and includes the replacement or repair of the device based on | 12 | | the patient's physical condition as medically necessary, | 13 | | excluding foot orthotics defined as an in-shoe device designed | 14 | | to support the structural components of the foot during | 15 | | weight-bearing activities. | 16 | | "Licensed provider" means a prosthetist, orthotist, or | 17 | | pedorthist licensed to practice in this State. | 18 | | "Prosthetic device" means an artificial device to replace, | 19 | | in whole or in part, an arm or leg and includes accessories | 20 | | essential to the effective use of the device and the | 21 | | replacement or repair of the device based on the patient's | 22 | | physical condition as medically necessary. | 23 | | (b) This amendatory Act of the 96th General Assembly shall |
| | | SB2195 Enrolled | - 2 - | LRB103 28476 BMS 54857 b |
|
| 1 | | provide benefits to any person covered thereunder for expenses | 2 | | incurred in obtaining a prosthetic or custom orthotic device | 3 | | from any Illinois licensed prosthetist, licensed orthotist, or | 4 | | licensed pedorthist as required under the Orthotics, | 5 | | Prosthetics, and Pedorthics Practice Act. | 6 | | (c) A group or individual major medical policy of accident | 7 | | or health insurance or managed care plan or medical, health, | 8 | | or hospital service corporation contract that provides | 9 | | coverage for prosthetic or custom orthotic care and is | 10 | | amended, delivered, issued, or renewed 6 months after the | 11 | | effective date of this amendatory Act of the 96th General | 12 | | Assembly must provide coverage for prosthetic and orthotic | 13 | | devices in accordance with this subsection (c). The coverage | 14 | | required under this Section shall be subject to the other | 15 | | general exclusions, limitations, and financial requirements of | 16 | | the policy, including coordination of benefits, participating | 17 | | provider requirements, utilization review of health care | 18 | | services, including review of medical necessity, case | 19 | | management, and experimental and investigational treatments, | 20 | | and other managed care provisions under terms and conditions | 21 | | that are no less favorable than the terms and conditions that | 22 | | apply to substantially all medical and surgical benefits | 23 | | provided under the plan or coverage. | 24 | | (d) With respect to an enrollee at any age, in addition to | 25 | | coverage of a prosthetic or custom orthotic device required by | 26 | | this Section, benefits shall be provided for a prosthetic or |
| | | SB2195 Enrolled | - 3 - | LRB103 28476 BMS 54857 b |
|
| 1 | | custom orthotic device determined by the enrollee's provider | 2 | | to be the most appropriate model that is medically necessary | 3 | | for the enrollee to perform physical activities, as | 4 | | applicable, such as running, biking, swimming, and lifting | 5 | | weights, and to maximize the enrollee's whole body health and | 6 | | strengthen the lower and upper limb function. | 7 | | (e) The requirements of this Section do not constitute an | 8 | | addition to this State's essential health benefits that | 9 | | requires defrayal of costs by this State pursuant to 42 U.S.C. | 10 | | 18031(d)(3)(B). | 11 | | (f) (d) The policy or plan or contract may require prior | 12 | | authorization for the prosthetic or orthotic devices in the | 13 | | same manner that prior authorization is required for any other | 14 | | covered benefit. | 15 | | (g) (e) Repairs and replacements of prosthetic and | 16 | | orthotic devices are also covered, subject to the co-payments | 17 | | and deductibles, unless necessitated by misuse or loss. | 18 | | (h) (f) A policy or plan or contract may require that, if | 19 | | coverage is provided through a managed care plan, the benefits | 20 | | mandated pursuant to this Section shall be covered benefits | 21 | | only if the prosthetic or orthotic devices are provided by a | 22 | | licensed provider employed by a provider service who contracts | 23 | | with or is designated by the carrier, to the extent that the | 24 | | carrier provides in-network and out-of-network service, the | 25 | | coverage for the prosthetic or orthotic device shall be | 26 | | offered no less extensively. |
| | | SB2195 Enrolled | - 4 - | LRB103 28476 BMS 54857 b |
|
| 1 | | (i) (g) The policy or plan or contract shall also meet | 2 | | adequacy requirements as established by the Health Care | 3 | | Reimbursement Reform Act of 1985 of the Illinois Insurance | 4 | | Code. | 5 | | (j) (h) This Section shall not apply to accident only, | 6 | | specified disease, short-term hospital or medical, hospital | 7 | | confinement indemnity, credit, dental, vision, Medicare | 8 | | supplement, long-term care, basic hospital and | 9 | | medical-surgical expense coverage, disability income insurance | 10 | | coverage, coverage issued as a supplement to liability | 11 | | insurance, workers' compensation insurance, or automobile | 12 | | medical payment insurance.
| 13 | | (Source: P.A. 96-833, eff. 6-1-10 .)
| 14 | | Section 99. Effective date. This Act takes effect January | 15 | | 1, 2025.
|
|