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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;and26 (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.)