SB2195 EnrolledLRB103 28476 BMS 54857 b

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 356z.18 as follows:
6    (215 ILCS 5/356z.18)
7    Sec. 356z.18. Prosthetic and customized orthotic devices.
8    (a) For the purposes of this Section:
9    "Customized orthotic device" means a supportive device for
10the body or a part of the body, the head, neck, or extremities,
11and includes the replacement or repair of the device based on
12the patient's physical condition as medically necessary,
13excluding foot orthotics defined as an in-shoe device designed
14to support the structural components of the foot during
15weight-bearing activities.
16    "Licensed provider" means a prosthetist, orthotist, or
17pedorthist licensed to practice in this State.
18    "Prosthetic device" means an artificial device to replace,
19in whole or in part, an arm or leg and includes accessories
20essential to the effective use of the device and the
21replacement or repair of the device based on the patient's
22physical condition as medically necessary.
23    (b) This amendatory Act of the 96th General Assembly shall



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1provide benefits to any person covered thereunder for expenses
2incurred in obtaining a prosthetic or custom orthotic device
3from any Illinois licensed prosthetist, licensed orthotist, or
4licensed pedorthist as required under the Orthotics,
5Prosthetics, and Pedorthics Practice Act.
6    (c) A group or individual major medical policy of accident
7or health insurance or managed care plan or medical, health,
8or hospital service corporation contract that provides
9coverage for prosthetic or custom orthotic care and is
10amended, delivered, issued, or renewed 6 months after the
11effective date of this amendatory Act of the 96th General
12Assembly must provide coverage for prosthetic and orthotic
13devices in accordance with this subsection (c). The coverage
14required under this Section shall be subject to the other
15general exclusions, limitations, and financial requirements of
16the policy, including coordination of benefits, participating
17provider requirements, utilization review of health care
18services, including review of medical necessity, case
19management, and experimental and investigational treatments,
20and other managed care provisions under terms and conditions
21that are no less favorable than the terms and conditions that
22apply to substantially all medical and surgical benefits
23provided under the plan or coverage.
24    (d) With respect to an enrollee at any age, in addition to
25coverage of a prosthetic or custom orthotic device required by
26this Section, benefits shall be provided for a prosthetic or



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1custom orthotic device determined by the enrollee's provider
2to be the most appropriate model that is medically necessary
3for the enrollee to perform physical activities, as
4applicable, such as running, biking, swimming, and lifting
5weights, and to maximize the enrollee's whole body health and
6strengthen the lower and upper limb function.
7    (e) The requirements of this Section do not constitute an
8addition to this State's essential health benefits that
9requires defrayal of costs by this State pursuant to 42 U.S.C.
11    (f) (d) The policy or plan or contract may require prior
12authorization for the prosthetic or orthotic devices in the
13same manner that prior authorization is required for any other
14covered benefit.
15    (g) (e) Repairs and replacements of prosthetic and
16orthotic devices are also covered, subject to the co-payments
17and deductibles, unless necessitated by misuse or loss.
18    (h) (f) A policy or plan or contract may require that, if
19coverage is provided through a managed care plan, the benefits
20mandated pursuant to this Section shall be covered benefits
21only if the prosthetic or orthotic devices are provided by a
22licensed provider employed by a provider service who contracts
23with or is designated by the carrier, to the extent that the
24carrier provides in-network and out-of-network service, the
25coverage for the prosthetic or orthotic device shall be
26offered no less extensively.



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1    (i) (g) The policy or plan or contract shall also meet
2adequacy requirements as established by the Health Care
3Reimbursement Reform Act of 1985 of the Illinois Insurance
5    (j) (h) This Section shall not apply to accident only,
6specified disease, short-term hospital or medical, hospital
7confinement indemnity, credit, dental, vision, Medicare
8supplement, long-term care, basic hospital and
9medical-surgical expense coverage, disability income insurance
10coverage, coverage issued as a supplement to liability
11insurance, workers' compensation insurance, or automobile
12medical payment insurance.
13(Source: P.A. 96-833, eff. 6-1-10.)
14    Section 99. Effective date. This Act takes effect January
151, 2025.