State of Illinois
92nd General Assembly
Legislation

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92_HB3567

 
                                               LRB9208337JSpc

 1        AN ACT concerning insurance.

 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
10    is amended, delivered, issued, or renewed after the effective
11    date  of  this  amendatory Act of 1998 shall provide coverage
12    for  outpatient  self-management  training   and   education,
13    equipment,  and  supplies,  as set forth in this Section, for
14    the treatment of  type  1  diabetes,  type  2  diabetes,  and
15    gestational diabetes 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
21    frequent   hospitalization   and   complications.    Diabetes
22    self-management training  shall  include  the  content  areas
23    listed in the National Standards for Diabetes Self-Management
24    Education  Programs  as  published  by  the American Diabetes
25    Association, including medical nutrition therapy.
26        "Medical  nutrition  therapy"  shall  have  the   meaning
27    ascribed  to  "medical  nutrition  care"  in the Dietetic and
28    Nutrition Services Practice Act.
29        "Physician"  means  a  physician  licensed  to   practice
30    medicine  in  all  of  its  branches  providing  care  to the
31    individual.
 
                            -2-                LRB9208337JSpc
 1        "Qualified provider" for an individual that  is  enrolled
 2    in:
 3             (1)  a  health  maintenance organization that uses a
 4        primary care physician to  control  access  to  specialty
 5        care  means  (A)  the individual's primary care physician
 6        licensed to practice medicine in all of its branches, (B)
 7        a physician licensed to practice medicine in all  of  its
 8        branches  to whom the individual has been referred by the
 9        primary care physician, or (C) a  certified,  registered,
10        or   licensed   network  health  care  professional  with
11        expertise in diabetes management to whom  the  individual
12        has been referred by the primary care physician.
13             (2)  an   insurance   plan  means  (A)  a  physician
14        licensed to practice medicine in all of its  branches  or
15        (B)  a  certified,  registered,  or  licensed health care
16        professional with expertise  in  diabetes  management  to
17        whom the individual has been referred by a physician.
18        (c)  Coverage    under    this   Section   for   diabetes
19    self-management   training,   including   medical   nutrition
20    education, shall be limited to the following:
21             (1)  Up  to  3  medically  necessary  visits  to   a
22        qualified  provider upon initial diagnosis of diabetes by
23        the patient's physician or, if diagnosis of diabetes  was
24        made  within one year prior to the effective date of this
25        amendatory Act of 1998 where the insured  was  a  covered
26        individual,  up  to  3  medically  necessary  visits to a
27        qualified provider within one year after  that  effective
28        date.
29             (2)  Up   to  2  medically  necessary  visits  to  a
30        qualified provider upon a determination  by  a  patient's
31        physician  that  a  significant  change  in the patient's
32        symptoms  or   medical   condition   has   occurred.    A
33        "significant   change"  in  condition  means  symptomatic
34        hyperglycemia  (greater  than  250  mg/dl   on   repeated
 
                            -3-                LRB9208337JSpc
 1        occasions), severe hypoglycemia (requiring the assistance
 2        of  another person), onset or progression of diabetes, or
 3        a significant change  in  medical  condition  that  would
 4        require a significantly different treatment regimen.
 5        Payment   by   the    insurer   or   health   maintenance
 6    organization   for   the   coverage   required  for  diabetes
 7    self-management training pursuant to the provisions  of  this
 8    Section is only required to be made for services provided. No
 9    coverage  is  required  for  additional  visits  beyond those
10    specified in items (1) and (2) of this subsection.
11        Coverage  under  this   subsection   (c)   for   diabetes
12    self-management   training  shall  be  subject  to  the  same
13    deductible,  co-payment,  and  co-insurance  provisions  that
14    apply  to  coverage  under  the  policy  for  other  services
15    provided by the same type of provider.
16        (d)  Coverage  shall  be  provided  for   the   following
17    equipment  when  medically  necessary  and  prescribed  by  a
18    physician  licensed  to  practice  medicine  in  all  of  its
19    branches.  Coverage  for the following items shall be subject
20    to  deductible,  co-payment   and   co-insurance   provisions
21    provided  for under the policy or a durable medical equipment
22    rider to the policy:
23             (1)  blood glucose monitors;
24             (2)  blood glucose monitors for the legally blind;
25             (3)  cartridges for the legally blind; and
26             (4)  lancets and lancing devices; and.
27             (5)  insulin pumps.
28        This subsection does not  apply  to  a  group  policy  of
29    accident and health insurance that does not provide a durable
30    medical equipment benefit.
31        (e)  Coverage   shall   be  provided  for  the  following
32    pharmaceuticals and supplies  when  medically  necessary  and
33    prescribed  by  a  physician licensed to practice medicine in
34    all of its branches. Coverage for the following  items  shall
 
                            -4-                LRB9208337JSpc
 1    be  subject to the same coverage, deductible, co-payment, and
 2    co-insurance provisions under the policy or a drug  rider  to
 3    the policy:
 4             (1)  insulin;
 5             (2)  syringes and needles;
 6             (3)  test strips for glucose monitors;
 7             (4)  FDA  approved oral agents used to control blood
 8        sugar; and
 9             (5)  glucagon emergency kits.
10        This subsection does not  apply  to  a  group  policy  of
11    accident  and  health  insurance that does not provide a drug
12    benefit.
13        (f)  Coverage shall be provided  for  regular  foot  care
14    exams  by  a  physician or by a physician to whom a physician
15    has referred the patient.  Coverage  for  regular  foot  care
16    exams  shall  be  subject to the same deductible, co-payment,
17    and co-insurance provisions that apply under the  policy  for
18    other services provided by the same type of provider.
19        (g)  If    authorized    by    a    physician,   diabetes
20    self-management training may be provided  as  a  part  of  an
21    office visit, group setting, or home visit.
22        (h)  This   Section   shall   not  apply  to  agreements,
23    contracts, or policies that provide coverage for a  specified
24    diagnosis or other limited benefit coverage.
25    (Source: P.A. 90-741, eff. 1-1-99.)

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