Rep. JoAnn D. Osmond

Filed: 4/5/2011

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2247

2    AMENDMENT NO. ______. Amend House Bill 2247 by replacing
3everything after the enacting clause with the following:
 
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 is
10amended, delivered, issued, or renewed after the effective date
11of 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:

 

 

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1    "Diabetes self-management training" means instruction in
2an outpatient setting which enables a diabetic patient to
3understand the diabetic management process and daily
4management of diabetic therapy as a means of avoiding frequent
5hospitalization and complications. Diabetes self-management
6training shall include the content areas listed in the National
7Standards for Diabetes Self-Management Education Programs as
8published by the American Diabetes Association, including
9medical nutrition therapy.
10    "Medical nutrition therapy" shall have the meaning
11ascribed to "medical nutrition care" in the Dietetic and
12Nutrition Services Practice Act.
13    "Physician" means a physician licensed to practice
14medicine in all of its branches providing care to the
15individual.
16    "Qualified provider" for an individual that is enrolled in:
17        (1) a health maintenance organization that uses a
18    primary care physician to control access to specialty care
19    means (A) the individual's primary care physician licensed
20    to practice medicine in all of its branches, (B) a
21    physician licensed to practice medicine in all of its
22    branches to whom the individual has been referred by the
23    primary care physician, or (C) a certified, registered, or
24    licensed network health care professional with expertise
25    in diabetes management to whom the individual has been
26    referred by the primary care physician.

 

 

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

 

 

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

 

 

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1prescribed by a physician licensed to practice medicine in all
2of its branches. Coverage for the following items shall be
3subject to the same coverage, deductible, co-payment, and
4co-insurance provisions under the policy or a drug rider to the
5policy:
6        (1) insulin;
7        (2) syringes and needles;
8        (3) test strips for glucose monitors;
9        (4) FDA approved oral agents used to control blood
10    sugar; and
11        (5) glucagon emergency kits.
12    An insurer or health maintenance organization may not
13request prior authorization for each of the pharmaceuticals and
14supplies listed in this subsection (e) more than once in a
15consecutive 12-month period unless the group policy of accident
16and health insurance has been amended, delivered, issued, or
17renewed during such period.
18    This subsection does not apply to a group policy of
19accident and health insurance that does not provide a drug
20benefit.
21    (f) Coverage shall be provided for regular foot care exams
22by a physician or by a physician to whom a physician has
23referred the patient. Coverage for regular foot care exams
24shall be subject to the same deductible, co-payment, and
25co-insurance provisions that apply under the policy for other
26services provided by the same type of provider.

 

 

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1    (g) If authorized by a physician, diabetes self-management
2training may be provided as a part of an office visit, group
3setting, or home visit.
4    (h) This Section shall not apply to agreements, contracts,
5or policies that provide coverage for a specified diagnosis or
6other limited benefit coverage.
7(Source: P.A. 90-741, eff. 1-1-99.)".