Full Text of HB2249 97th General Assembly
HB2249enr 97TH GENERAL ASSEMBLY |
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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 "medical nutrition care" in the Dietetic and | 8 | | Nutrition Services
Practice 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;
| 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 | 9 | | accident and health
insurance that does not provide a drug | 10 | | benefit.
| 11 | | (f) Coverage shall be provided for regular foot care exams | 12 | | by a
physician or by a
physician to whom a physician has | 13 | | referred the patient. Coverage
for regular foot care exams
| 14 | | shall be subject to the same deductible, co-payment, and | 15 | | co-insurance
provisions
that apply under the policy for
other | 16 | | services provided by the same type of provider.
| 17 | | (g) If authorized by a physician, diabetes self-management
| 18 | | training may be provided as a part of an office visit, group | 19 | | setting, or home
visit.
| 20 | | (h) This Section shall not apply to agreements, contracts, | 21 | | or policies that
provide coverage for a specified diagnosis or | 22 | | other limited benefit coverage.
| 23 | | (Source: P.A. 90-741, eff. 1-1-99.)
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