103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB0054

 

Introduced 1/20/2023, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356w

    Amends the Illinois Insurance Code. Provides that coverage for self-management training and education, equipment, and supplies for diabetes treatment shall include insulin pumps and medical supplies required for the use of an insulin pump when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches.


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A BILL FOR

 

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1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356w as follows:
 
6    (215 ILCS 5/356w)
7    Sec. 356w. Diabetes self-management training and
8education.
9    (a) A group policy of accident and health insurance that
10is amended, delivered, issued, or renewed after the effective
11date of this amendatory Act of 1998 shall provide coverage for
12outpatient self-management training and education, equipment,
13and supplies, as set forth in this Section, for the treatment
14of type 1 diabetes, type 2 diabetes, and gestational diabetes
15mellitus.
16    (b) As used in this Section:
17    "Diabetes self-management training" means instruction in
18an outpatient setting which enables a diabetic patient to
19understand the diabetic management process and daily
20management of diabetic therapy as a means of avoiding frequent
21hospitalization and complications. Diabetes self-management
22training shall include the content areas listed in the
23National Standards for Diabetes Self-Management Education

 

 

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1Programs as published by the American Diabetes Association,
2including medical nutrition therapy and education programs, as
3defined by the contract of insurance, that allow the patient
4to maintain an A1c level within the range identified in
5nationally recognized standards of care.
6    "Medical nutrition therapy" shall have the meaning
7ascribed to that term in the Dietitian Nutritionist Practice
8Act.
9    "Physician" means a physician licensed to practice
10medicine in all of its branches providing care to the
11individual.
12    "Qualified provider" for an individual that is enrolled
13in:
14        (1) a health maintenance organization that uses a
15    primary care physician to control access to specialty care
16    means (A) the individual's primary care physician licensed
17    to practice medicine in all of its branches, (B) a
18    physician licensed to practice medicine in all of its
19    branches to whom the individual has been referred by the
20    primary care physician, or (C) a certified, registered, or
21    licensed network health care professional with expertise
22    in diabetes management to whom the individual has been
23    referred by the primary care physician.
24        (2) an insurance plan means (A) a physician licensed
25    to practice medicine in all of its branches or (B) a
26    certified, registered, or licensed health care

 

 

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1    professional with expertise in diabetes management to whom
2    the individual has been referred by a physician.
3    (c) Coverage under this Section for diabetes
4self-management training, including medical nutrition
5education, shall be limited to the following:
6        (1) Up to 3 medically necessary visits to a qualified
7    provider upon initial diagnosis of diabetes by the
8    patient's physician or, if diagnosis of diabetes was made
9    within one year prior to the effective date of this
10    amendatory Act of 1998 where the insured was a covered
11    individual, up to 3 medically necessary visits to a
12    qualified provider within one year after that effective
13    date.
14        (2) Up to 2 medically necessary visits to a qualified
15    provider upon a determination by a patient's physician
16    that a significant change in the patient's symptoms or
17    medical condition has occurred. A "significant change" in
18    condition means symptomatic hyperglycemia (greater than
19    250 mg/dl on repeated occasions), severe hypoglycemia
20    (requiring the assistance of another person), onset or
21    progression of diabetes, or a significant change in
22    medical condition that would require a significantly
23    different treatment regimen.
24    Payment by the insurer or health maintenance organization
25for the coverage required for diabetes self-management
26training pursuant to the provisions of this Section is only

 

 

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1required to be made for services provided. No coverage is
2required for additional visits beyond those specified in items
3(1) and (2) of this subsection.
4    Coverage under this subsection (c) for diabetes
5self-management training shall be subject to the same
6deductible, co-payment, and co-insurance provisions that apply
7to coverage under the policy for other services provided by
8the same type of provider.
9    (d) Coverage shall be provided for the following equipment
10when medically necessary and prescribed by a physician
11licensed to practice medicine in all of its branches. Coverage
12for the following items shall be subject to deductible,
13co-payment and co-insurance provisions provided for under the
14policy or a durable medical equipment rider to the policy:
15        (1) blood glucose monitors;
16        (2) blood glucose monitors for the legally blind;
17        (3) cartridges for the legally blind; and
18        (4) lancets and lancing devices.
19    This subsection does not apply to a group policy of
20accident and health insurance that does not provide a durable
21medical equipment benefit.
22    (e) Coverage shall be provided for the following
23pharmaceuticals and supplies when medically necessary and
24prescribed by a physician licensed to practice medicine in all
25of its branches. Coverage for the following items shall be
26subject to the same coverage, deductible, co-payment, and

 

 

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1co-insurance provisions under the policy or a drug rider to
2the policy, except as otherwise provided for under Section
3356z.41:
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; and .
10        (6) insulin pumps and medical supplies required for
11    the use of an insulin pump.
12    This subsection does not apply to a group policy of
13accident and health insurance that does not provide a drug
14benefit.
15    (f) Coverage shall be provided for regular foot care exams
16by a physician or by a physician to whom a physician has
17referred the patient. Coverage for regular foot care exams
18shall be subject to the same deductible, co-payment, and
19co-insurance provisions that apply under the policy for other
20services provided by the same type of provider.
21    (g) If authorized by a physician, diabetes self-management
22training may be provided as a part of an office visit, group
23setting, or home visit.
24    (h) This Section shall not apply to agreements, contracts,
25or policies that provide coverage for a specified diagnosis or
26other limited benefit coverage.

 

 

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