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Public Act 103-0512


Public Act 0512 103RD GENERAL ASSEMBLY



Public Act 103-0512
SB2195 EnrolledLRB103 28476 BMS 54857 b

    AN ACT concerning regulation.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Illinois Insurance Code is amended by
changing Section 356z.18 as follows:
    (215 ILCS 5/356z.18)
    Sec. 356z.18. Prosthetic and customized orthotic devices.
    (a) For the purposes of this Section:
    "Customized orthotic device" means a supportive device for
the body or a part of the body, the head, neck, or extremities,
and includes the replacement or repair of the device based on
the patient's physical condition as medically necessary,
excluding foot orthotics defined as an in-shoe device designed
to support the structural components of the foot during
weight-bearing activities.
    "Licensed provider" means a prosthetist, orthotist, or
pedorthist licensed to practice in this State.
    "Prosthetic device" means an artificial device to replace,
in whole or in part, an arm or leg and includes accessories
essential to the effective use of the device and the
replacement or repair of the device based on the patient's
physical condition as medically necessary.
    (b) This amendatory Act of the 96th General Assembly shall
provide benefits to any person covered thereunder for expenses
incurred in obtaining a prosthetic or custom orthotic device
from any Illinois licensed prosthetist, licensed orthotist, or
licensed pedorthist as required under the Orthotics,
Prosthetics, and Pedorthics Practice Act.
    (c) A group or individual major medical policy of accident
or health insurance or managed care plan or medical, health,
or hospital service corporation contract that provides
coverage for prosthetic or custom orthotic care and is
amended, delivered, issued, or renewed 6 months after the
effective date of this amendatory Act of the 96th General
Assembly must provide coverage for prosthetic and orthotic
devices in accordance with this subsection (c). The coverage
required under this Section shall be subject to the other
general exclusions, limitations, and financial requirements of
the policy, including coordination of benefits, participating
provider requirements, utilization review of health care
services, including review of medical necessity, case
management, and experimental and investigational treatments,
and other managed care provisions under terms and conditions
that are no less favorable than the terms and conditions that
apply to substantially all medical and surgical benefits
provided under the plan or coverage.
    (d) With respect to an enrollee at any age, in addition to
coverage of a prosthetic or custom orthotic device required by
this Section, benefits shall be provided for a prosthetic or
custom orthotic device determined by the enrollee's provider
to be the most appropriate model that is medically necessary
for the enrollee to perform physical activities, as
applicable, such as running, biking, swimming, and lifting
weights, and to maximize the enrollee's whole body health and
strengthen the lower and upper limb function.
    (e) The requirements of this Section do not constitute an
addition to this State's essential health benefits that
requires defrayal of costs by this State pursuant to 42 U.S.C.
    (f) (d) The policy or plan or contract may require prior
authorization for the prosthetic or orthotic devices in the
same manner that prior authorization is required for any other
covered benefit.
    (g) (e) Repairs and replacements of prosthetic and
orthotic devices are also covered, subject to the co-payments
and deductibles, unless necessitated by misuse or loss.
    (h) (f) A policy or plan or contract may require that, if
coverage is provided through a managed care plan, the benefits
mandated pursuant to this Section shall be covered benefits
only if the prosthetic or orthotic devices are provided by a
licensed provider employed by a provider service who contracts
with or is designated by the carrier, to the extent that the
carrier provides in-network and out-of-network service, the
coverage for the prosthetic or orthotic device shall be
offered no less extensively.
    (i) (g) The policy or plan or contract shall also meet
adequacy requirements as established by the Health Care
Reimbursement Reform Act of 1985 of the Illinois Insurance
    (j) (h) This Section shall not apply to accident only,
specified disease, short-term hospital or medical, hospital
confinement indemnity, credit, dental, vision, Medicare
supplement, long-term care, basic hospital and
medical-surgical expense coverage, disability income insurance
coverage, coverage issued as a supplement to liability
insurance, workers' compensation insurance, or automobile
medical payment insurance.
(Source: P.A. 96-833, eff. 6-1-10.)
    Section 99. Effective date. This Act takes effect January
1, 2025.

Effective Date: 1/1/2025