215 ILCS 5/356w

(215 ILCS 5/356w)

Sec. 356w. Diabetes self-management training and education.

(a) A group policy of accident and health insurance that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of 1998 shall provide coverage for outpatient self-management training and education, equipment, and supplies, as set forth in this Section, for the treatment of type 1 diabetes, type 2 diabetes, and gestational diabetes mellitus.

(b) As used in this Section:

"Diabetes self-management training" means instruction in an outpatient setting which enables a diabetic patient to understand the diabetic management process and daily management of diabetic therapy as a means of avoiding frequent hospitalization and complications. Diabetes self-management training shall include the content areas listed in the National Standards for Diabetes Self-Management Education Programs as published by the American Diabetes Association, including medical nutrition therapy and education programs, as defined by the contract of insurance, that allow the patient to maintain an A1c level within the range identified in nationally recognized standards of care.

"Medical nutrition therapy" shall have the meaning ascribed to that term in the Dietitian Nutritionist Practice Act.

"Physician" means a physician licensed to practice medicine in all of its branches providing care to the individual.

"Qualified provider" for an individual that is enrolled in:

(1) a health maintenance organization that uses a primary care physician to control access to specialty care means (A) the individual's primary care physician licensed to practice medicine in all of its branches, (B) a physician licensed to practice medicine in all of its branches to whom the individual has been referred by the primary care physician, or (C) a certified, registered, or licensed network health care professional with expertise in diabetes management to whom the individual has been referred by the primary care physician.

(2) an insurance plan means (A) a physician licensed to practice medicine in all of its branches or (B) a certified, registered, or licensed health care professional with expertise in diabetes management to whom the individual has been referred by a physician.

(c) Coverage under this Section for diabetes self-management training, including medical nutrition education, shall be limited to the following:

(1) Up to 3 medically necessary visits to a qualified provider upon initial diagnosis of diabetes by the patient's physician or, if diagnosis of diabetes was made within one year prior to the effective date of this amendatory Act of 1998 where the insured was a covered individual, up to 3 medically necessary visits to a qualified provider within one year after that effective date.

(2) Up to 2 medically necessary visits to a qualified provider upon a determination by a patient's physician that a significant change in the patient's symptoms or medical condition has occurred. A "significant change" in condition means symptomatic hyperglycemia (greater than 250 mg/dl on repeated occasions), severe hypoglycemia (requiring the assistance of another person), onset or progression of diabetes, or a significant change in medical condition that would require a significantly different treatment regimen.

Payment by the insurer or health maintenance organization for the coverage required for diabetes self-management training pursuant to the provisions of this Section is only required to be made for services provided. No coverage is required for additional visits beyond those specified in items (1) and (2) of this subsection.

Coverage under this subsection (c) for diabetes self-management training shall be subject to the same deductible, co-payment, and co-insurance provisions that apply to coverage under the policy for other services provided by the same type of provider.

(d) Coverage shall be provided for the following equipment when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to deductible, co-payment and co-insurance provisions provided for under the policy or a durable medical equipment rider to the policy:

(1) blood glucose monitors;

(2) blood glucose monitors for the legally blind;

(3) cartridges for the legally blind; and

(4) lancets and lancing devices.

This subsection does not apply to a group policy of accident and health insurance that does not provide a durable medical equipment benefit.

(e) Coverage shall be provided for the following pharmaceuticals and supplies when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches. Coverage for the following items shall be subject to the same coverage, deductible, co-payment, and co-insurance provisions under the policy or a drug rider to the policy, except as otherwise provided for under Section 356z.41:

(1) insulin;

(2) syringes and needles;

(3) test strips for glucose monitors;

(4) FDA approved oral agents used to control blood sugar; and

(5) glucagon emergency kits.

This subsection does not apply to a group policy of accident and health insurance that does not provide a drug benefit.

(f) Coverage shall be provided for regular foot care exams by a physician or by a physician to whom a physician has referred the patient. Coverage for regular foot care exams shall be subject to the same deductible, co-payment, and co-insurance provisions that apply under the policy for other services provided by the same type of provider.

(g) If authorized by a physician, diabetes self-management training may be provided as a part of an office visit, group setting, or home visit.

(h) This Section shall not apply to agreements, contracts, or policies that provide coverage for a specified diagnosis or other limited benefit coverage.

(Source: P.A. 101-625, eff. 1-1-21.)