(215 ILCS 5/356z.30a) Sec. 356z.30a. Coverage for hearing instruments. (a) As used in this Section: "Hearing care professional" means a person who is a licensed hearing instrument dispenser, licensed audiologist, or a licensed physician. "Hearing instrument" means any wearable non-disposable instrument or device designed to aid or compensate for impaired human hearing and any parts, attachments, or accessories for the instrument or device, including an ear mold but excluding batteries and cords. "Related services" means those services necessary to assess, select, and adjust or fit the hearing instrument to ensure optimal performance, including, but not limited to: audiological exams, replacement ear molds, and repairs to the hearing instrument. (b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 101st General Assembly shall offer, for an additional premium and subject to the insurer's standard of insurability, optional coverage or optional reimbursement for hearing instruments and related services for all individuals when a hearing care professional prescribes a hearing instrument to augment communication. (c) This optional coverage shall be subject to all applicable copayments, coinsurance, deductibles, and out-of-pocket limits for the cost of a hearing instrument for each ear, as needed, as well as related services, with a
maximum for the hearing instrument and related services of no
more than $2,500 per hearing instrument every 24 months. (d) Nothing in this Section precludes an insured from selecting a hearing instrument that costs more than the amount covered by a plan of accident and health insurance or a managed care plan and paying the uncovered cost at his or her own expense. (e) Nothing in this Section shall be construed to require a group policy of accident and health insurance to provide coverage if the group is unable to meet mandatory minimum participation requirements set by the insurer.
(Source: P.A. 101-393, eff. 1-1-20 .) |
(215 ILCS 5/356z.31) Sec. 356z.31. Recovery housing for persons with substance use
disorders. (a) Definitions. As used in this Section: "Substance use disorder" and "case management" have the meanings ascribed to those terms in Section 1-10 of the Substance Use Disorder Act. "Hospital" means a facility licensed by the Department of Public Health under the Hospital Licensing Act. "Federally qualified health center" means a facility as defined in Section 1905(l)(2)(B) of the federal Social Security Act. "Recovery housing" means a residential extended care treatment facility or a recovery home as defined and licensed in 77 Illinois Administrative Code, Part 2060, by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery. (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2019 (the effective date of Public Act 100-1065) may provide coverage for residential extended care services and supports for persons recovery housing for persons with substance use disorders who are at risk of a relapse following discharge from a health care clinic, federally qualified health center, hospital withdrawal management program or any other licensed withdrawal management program, or hospital emergency department so long as all of the following conditions are met: (1) A health care clinic, federally qualified health | ||
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(2) The recovery housing is administered by a | ||
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(3) The recovery housing is administered by a | ||
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(c) Based on the individualized needs assessment, any coverage provided in accordance with this Section may include, but not be limited to, the following: (1) Substance use disorder treatment services that | ||
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(2) Transitional housing services, including food or | ||
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(3) Individualized case management and referral | ||
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(4)
Job training or placement services. (d) The insurer may rate each community-based agency that is licensed by or under contract with the Department of Human Services, Division of Substance Use Prevention and Recovery to provide recovery housing based on an evaluation of each agency's ability to: (1) reduce health care costs; (2) reduce recidivism rates for persons suffering | ||
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(3) improve outcomes; (4) track persons with substance use disorders; and (5) improve the quality of life of persons with | ||
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The insurer may publish the results of the ratings on its official website and shall, on an annual basis, update the posted results. (e) The Department of Insurance may adopt any rules necessary to implement the provisions of this Section in accordance with the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 100-1065, eff. 1-1-19; 101-81, eff. 7-12-19.) |
(215 ILCS 5/356z.32) Sec. 356z.32. Coverage for fertility preservation services. (a) As used in this Section: "Iatrogenic infertility" means an impairment of | ||
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"May directly or indirectly cause" means the likely | ||
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"Standard fertility preservation services" means | ||
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(b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after January 1, 2019 (the effective date of Public Act 100-1102) must provide coverage for medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee. (c) In determining coverage pursuant to this Section, an insurer shall not discriminate based on an individual's expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions, nor based on personal characteristics, including age, sex, sexual orientation, or marital status. (d) If, at any time before or after January 1, 2019 (the effective date of Public Act 100-1102), the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register, publishes a comment in the Federal Register, or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Pub. L. 111–148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of coverage for fertility preservation services, then this Section is inoperative with respect to all such coverage other than that authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for fertility preservation services.
(Source: P.A. 100-1102, eff. 1-1-19; 101-81, eff. 7-12-19.) |
(215 ILCS 5/356z.33) (Text of Section before amendment by P.A. 103-454 ) Sec. 356z.33. Coverage for epinephrine injectors. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act.
(Source: P.A. 101-281, eff. 1-1-20; 102-558, eff. 8-20-21.) (Text of Section after amendment by P.A. 103-454 ) Sec. 356z.33. Coverage for epinephrine injectors. (a) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-281) shall provide coverage for medically necessary epinephrine injectors for persons 18 years of age or under. As used in this Section, "epinephrine injector" has the meaning given to that term in Section 5 of the Epinephrine Injector Act. (b) An insurer that provides coverage for medically necessary epinephrine injectors shall limit the total amount that an insured is required to pay for a twin-pack of medically necessary epinephrine injectors at an amount not to exceed $60, regardless of the type of epinephrine injector. (c) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (b). (d) The Department may adopt rules as necessary to implement and administer this Section.
(Source: P.A. 102-558, eff. 8-20-21; 103-454, eff. 1-1-25.) |
(215 ILCS 5/356z.34) Sec. 356z.34. Coverage for cardiopulmonary monitors. A group or individual policy of accident and health insurance amended, delivered, issued, or renewed after January 1, 2020 (the effective date of Public Act 101-218) shall provide coverage for cardiopulmonary monitors determined to be medically necessary for a person 18 years old or younger who has had a cardiopulmonary event.
(Source: P.A. 101-218, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.35) Sec. 356z.35. Long-term antibiotic therapy for tick-borne diseases. (a) As used in this Section: "Long-term antibiotic therapy" means the administration of oral, intramuscular, or intravenous antibiotics singly or in combination for periods of time in excess of 4 weeks. "Tick-borne disease" means a disease caused when an infected tick bites a person and the tick's saliva transmits an infectious agent (bacteria, viruses, or parasites) that can cause illness, including, but not limited to, the following: (1) a severe infection with borrelia burgdorferi; (2) a late stage, persistent, or chronic infection or | ||
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(3) an infection with other strains of borrelia or a | ||
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(4) the presence of signs or symptoms compatible with | ||
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(b) An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-371) shall provide coverage for long-term antibiotic therapy, including necessary office visits and ongoing testing, for a person with a tick-borne disease when determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches after making a thorough evaluation of the person's symptoms, diagnostic test results, or response to treatment. An experimental drug shall be covered as a long-term antibiotic therapy if it is approved for an indication by the United States Food and Drug Administration. A drug, including an experimental drug, shall be covered for an off-label use in the treatment of a tick-borne disease if the drug has been approved by the United States Food and Drug Administration.
(Source: P.A. 101-371, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.36) Sec. 356z.36. Coverage of treatment models for early treatment of serious mental illnesses. (a) For purposes of early treatment of a serious mental illness in a child or young adult under age 26, a group or individual policy of accident and health insurance, or managed care plan, that is amended, delivered, issued, or renewed after December 31, 2020 shall provide coverage of the following bundled, evidence-based treatment: (1) Coordinated specialty care for first episode | ||
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(2) Assertive community treatment (ACT) and community | ||
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(b) Adherence to the clinical models. For purposes of ensuring adherence to the coordinated specialty care for first episode psychosis treatment model, only providers contracted with the Department of Human Services' Division of Mental Health to be FIRST.IL providers to deliver coordinated specialty care for first episode psychosis treatment shall be permitted to provide such treatment in accordance with this Section and such providers must adhere to the fidelity of the treatment model. For purposes of ensuring fidelity to ACT and CST, only providers certified to provide ACT and CST by the Department of Human Services' Division of Mental Health and approved to provide ACT and CST by the Department of Healthcare and Family Services, or its designee, in accordance with 89 Ill. Adm. Code 140, shall be permitted to provide such services under this Section and such providers shall be required to adhere to the fidelity of the models. (c) Development of medical necessity criteria for coverage. Within 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall lead and convene a workgroup that includes the Department of Human Services' Division of Mental Health, the Department of Healthcare and Family Services, providers of the treatment models listed in this Section, and insurers operating in Illinois to develop medical necessity criteria for such treatment models for purposes of coverage under this Section. The workgroup shall use the medical necessity criteria the State and other states use as guidance for establishing medical necessity for insurance coverage. The Department of Insurance shall adopt a rule that defines medical necessity for each of the 3 treatment models listed in this Section by no later than June 30, 2020 based on the workgroup's recommendations. (d) For purposes of credentialing the mental health professionals and other medical professionals that are part of a coordinated specialty care for first episode psychosis treatment team, an ACT team, or a CST team, the credentialing of the psychiatrist or the licensed clinical leader of the treatment team shall qualify all members of the treatment team to be credentialed with the insurer. (e) Payment for the services performed under the treatment models listed in this Section shall be based on a bundled treatment model or payment, rather than payment for each separate service delivered by a treatment team member. By no later than 6 months after January 1, 2020 (the effective date of Public Act 101-461), the Department of Insurance shall convene a workgroup of Illinois insurance companies and Illinois mental health treatment providers that deliver the bundled treatment approaches listed in this Section to determine a coding solution that allows for these bundled treatment models to be coded and paid for as a bundle of services, similar to intensive outpatient treatment where multiple services are covered under one billing code or a bundled set of billing codes. The coding solution shall ensure that services delivered using coordinated specialty care for first episode psychosis treatment, ACT, or CST are provided and billed as a bundled service, rather than for each individual service provided by a treatment team member, which would deconstruct the evidence-based practice. The coding solution shall be reached prior to coverage, which shall begin for plans amended, delivered, issued, or renewed after December 31, 2020, to ensure coverage of the treatment team approaches as intended by this Section. (f) If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, adopts rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, under any provision of the Patient Protection and Affordable Care Act (P.L. 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(b), or any successor provision, to defray the cost of any coverage for serious mental illnesses or serious emotional disturbances outlined in this Section, then the requirement that a group or individual policy of accident and health insurance or managed care plan cover the bundled treatment approaches listed in this Section is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of the coverage. (g) After 5 years following full implementation of this Section, if requested by an insurer, the Department of Insurance shall contract with an independent third party with expertise in analyzing health insurance premiums and costs to perform an independent analysis of the impact coverage of the team-based treatment models listed in this Section has had on insurance premiums in Illinois. If premiums increased by more than 1% annually solely due to coverage of these treatment models, coverage of these models shall no longer be required. (h) The Department of Insurance shall adopt any rules necessary to implement the provisions of this Section by no later than June 30, 2020.
(Source: P.A. 101-461, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.37) Sec. 356z.37. Whole body skin examination. An individual or group policy of accident and health insurance shall cover, without imposing a deductible, coinsurance, copayment, or any other cost-sharing requirement upon the insured patient, one annual office visit, using appropriate routine evaluation and management Current Procedural Terminology codes or any successor codes, for a whole body skin examination for lesions suspicious for skin cancer. The whole body skin examination shall be indicated using an appropriate International Statistical Classification of Diseases and Related Health Problems code or any successor codes. The provisions of this Section do not apply to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to 26 U.S.C. 223.
(Source: P.A. 101-500, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.38) Sec. 356z.38. Human breast milk coverage. (a) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is an infant under the age of 6 months, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the infant's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the infant's birth weight is below 1,500 | ||
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(B) the infant has a congenital or acquired | ||
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(C) the infant has infant hypoglycemia; (D) the infant has congenital heart disease; (E) the infant has had or will have an organ | ||
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(F) the infant has sepsis; or (G) the infant has any other serious congenital | ||
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(b) Notwithstanding any other provision of this Act, pasteurized donated human breast milk, which may include human milk fortifiers if indicated by a prescribing licensed medical practitioner, shall be covered under an individual or group health insurance for persons who are otherwise eligible for coverage under this Act if the covered person is a child 6 months through 12 months of age, a licensed medical practitioner prescribes the milk for the covered person, and all of the following conditions are met: (1) the milk is obtained from a human milk bank that | ||
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(2) the child's mother is medically or physically | ||
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(3) the milk has been determined to be medically | ||
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(4) one or more of the following applies: (A) the child has spinal muscular atrophy; (B) the child's birth weight was below 1,500 | ||
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(C) the child has had or will have an organ | ||
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(D) the child has a congenital or acquired | ||
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(Source: P.A. 101-511, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.39) Sec. 356z.39. Coverage of the psychiatric Collaborative Care Model. (a) As used in this Section, "psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method, which includes a formal collaborative arrangement among a primary care team consisting of a primary care provider, a care manager, and a psychiatric consultant, and includes, but is not limited to, the following elements: (1) care directed by the primary care team; (2) structured care management; (3) regular assessments of clinical status using | ||
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(4) modification of treatment as appropriate. (b) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-574) or managed care organization that provides mental health benefits shall provide reimbursement for benefits that are delivered through the psychiatric Collaborative Care Model. The following American Medical Association 2018 current procedural terminology codes and Healthcare Common Procedure Coding System code shall be used to bill for benefits delivered through the psychiatric Collaborative Care Model: (1) 99492; (2) 99493; (3) 99494; and (4) G0512. (c) The Director of Insurance shall update the billing codes in subsection (b) if there are any alterations or additions to the billing codes for the psychiatric Collaborative Care Model. (d) An individual or group policy or managed care organization that provides benefits under this Section may deny reimbursement of any billing code listed in this Section on the grounds of medical necessity if such medical necessity determinations are in compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and its implementing and related regulations and that such determinations are made in accordance with the utilization review requirements under Section 85 of the Managed Care Reform and Patient Rights Act.
(Source: P.A. 101-574, eff. 1-1-20; 102-558, eff. 8-20-21.) |
(215 ILCS 5/356z.40) Sec. 356z.40. Pregnancy and postpartum coverage. (a) An individual or group policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for pregnancy and newborn care in accordance with 42 U.S.C. 18022(b) regarding essential health benefits. (b) Benefits under this Section shall be as follows: (1) An individual who has been identified as | ||
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(2) An individual shall have access to medically | ||
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(3) The benefits provided for inpatient and | ||
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(4) The benefits for the first 48 hours of initiation | ||
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(5) If an insurer determines that continued inpatient | ||
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(6) Except as otherwise stated in this subsection | ||
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(7) The benefits required by paragraphs (2) and (6) | ||
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(Source: P.A. 102-665, eff. 10-8-21.) |
(215 ILCS 5/356z.41) (Text of Section before amendment by P.A. 103-429 ) Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information. (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is
administered to a patient intravenously. (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly. (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $100, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription. (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c). (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section. (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements. (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 101-625, eff. 1-1-21 .) (Text of Section after amendment by P.A. 103-429 ) Sec. 356z.41. Cost sharing in prescription insulin drugs; limits; confidentiality of rebate information. (a) As used in this Section, "prescription insulin drug" means a prescription drug that contains insulin and is used to control blood glucose levels to treat diabetes but does not include an insulin drug that is
administered to a patient intravenously. (b) This Section applies to a group or individual policy of accident and health insurance amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly. (c) An insurer that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the insurer offers shall limit the total amount that an insured is required to pay for a 30-day supply of covered prescription insulin drugs at an amount not to exceed $35, regardless of the quantity or type of covered prescription insulin drug used to fill the insured's prescription. (d) Nothing in this Section prevents an insurer from reducing an insured's cost sharing by an amount greater than the amount specified in subsection (c). (e) The Director may use any of the Director's enforcement powers to obtain an insurer's compliance with this Section. (f) The Department may adopt rules as necessary to implement and administer this Section and to align it with federal requirements. (g) On January 1 of each year, the limit on the amount that an insured is required to pay for a 30-day supply of a covered prescription insulin drug shall increase by a percentage equal to the percentage change from the preceding year in the medical care component of the Consumer Price Index of the Bureau of Labor Statistics of the United States Department of Labor.
(Source: P.A. 103-429, eff. 7-1-25.) |
(215 ILCS 5/356z.42) Sec. 356z.42. (Repealed).
(Source: P.A. 101-625, eff. 1-24-20. Repealed internally, eff. 12-31-20.) |
(215 ILCS 5/356z.43) Sec. 356z.43. (Repealed).
(Source: P.A. 102-813, eff. 5-13-22. Repealed internally, eff. 1-1-22.) |
(215 ILCS 5/356z.44) Sec. 356z.44. Vitamin D testing. (a) As used in this Section, "vitamin D testing" means vitamin D blood testing that measures the level of vitamin D in an individual's blood. (b) A group or individual policy of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for vitamin D testing recommended by a health care provider in accordance with vitamin D deficiency risk factors identified by the United States Centers for Disease Control and Prevention. Risk factors for vitamin D deficiency include, but are not limited to: (1) having osteoporosis or other bone-health | ||
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(2) having conditions that affect fat absorption, | ||
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(3) routinely taking medications that interfere | ||
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(4) beneficiaries aged 55 and older; (5) having a darker skin color; (6) inadequate sunlight exposure; (7) being obese; (8) previous diagnosis of diabetes or kidney | ||
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(9) exhibiting poor muscle strength or constant | ||
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(Source: P.A. 102-530, eff. 1-1-22 .) |