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| Public Act 097-0281 | ||||
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Section 356w as follows:
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(215 ILCS 5/356w)
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Sec. 356w. Diabetes self-management training and | ||||
education.
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(a) A group policy of accident and health insurance that is | ||||
amended,
delivered,
issued, or renewed after the
effective date | ||||
of this amendatory Act of 1998 shall provide coverage for
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outpatient self-management
training and education, equipment, | ||||
and supplies, as set forth in this Section,
for the treatment | ||||
of type 1 diabetes, type 2 diabetes, and gestational diabetes
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mellitus.
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(b) As used in this Section:
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"Diabetes self-management training"
means instruction in | ||||
an outpatient setting
which enables a diabetic patient to | ||||
understand the diabetic management process
and daily | ||||
management of
diabetic therapy as a means of avoiding frequent | ||||
hospitalization and
complications. Diabetes self-management | ||||
training shall include
the content areas listed in the National | ||||
Standards for Diabetes Self-Management
Education Programs as | ||||
published by the American Diabetes Association, including
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medical nutrition therapy and education programs, as defined by | ||
the contract of insurance, that allow the patient to maintain | ||
an A1c level within the range identified in nationally | ||
recognized standards of care.
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"Medical nutrition therapy" shall have the meaning
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ascribed to "medical nutrition care" in the Dietetic and | ||
Nutrition Services
Practice Act.
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"Physician" means a
physician licensed to practice | ||
medicine in all of
its branches providing care to the | ||
individual.
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"Qualified provider" for an
individual that is enrolled in:
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(1) a health maintenance organization that uses a
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primary
care physician to
control access to specialty care | ||
means (A) the individual's primary care
physician licensed | ||
to practice
medicine in all of its branches, (B) a | ||
physician licensed to practice
medicine in all of its | ||
branches to
whom the individual has been referred by the | ||
primary care physician, or (C) a
certified, registered, or
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licensed network health care professional with expertise | ||
in diabetes management
to whom the individual
has been | ||
referred by the primary care physician.
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(2) an insurance plan
means (A) a physician licensed to | ||
practice medicine in
all of its branches or (B) a
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certified, registered, or licensed health care | ||
professional with expertise in
diabetes management to whom | ||
the individual has been referred by a physician.
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(c) Coverage under this Section for diabetes | ||
self-management training,
including medical nutrition
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education, shall be limited to the following:
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(1) Up to 3 medically necessary visits to a qualified | ||
provider upon
initial diagnosis of diabetes
by the | ||
patient's
physician or, if diagnosis of diabetes was made | ||
within one year prior to the
effective date of
this | ||
amendatory Act
of 1998 where the insured was a covered | ||
individual, up to 3 medically necessary
visits to a | ||
qualified provider within one
year after that
effective
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date.
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(2) Up to 2 medically necessary visits to a qualified | ||
provider upon a
determination by a
patient's
physician that | ||
a significant change in the patient's symptoms or medical
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condition has
occurred. A "significant change" in | ||
condition means symptomatic
hyperglycemia (greater than | ||
250 mg/dl on repeated occasions), severe
hypoglycemia | ||
(requiring the assistance of another person), onset or | ||
progression
of diabetes, or a significant change in medical | ||
condition that would require a
significantly different | ||
treatment regimen.
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Payment by the insurer or health maintenance organization | ||
for the coverage
required for diabetes self-management | ||
training pursuant to the provisions of
this Section is only | ||
required to be made for services provided.
No coverage is | ||
required for additional visits beyond those specified in items
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(1) and (2) of this subsection.
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Coverage under this subsection (c) for diabetes | ||
self-management training
shall
be subject to the same
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deductible, co-payment, and co-insurance provisions that apply | ||
to coverage
under
the policy for other
services provided by the | ||
same type of provider.
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(d) Coverage shall be provided for the following
equipment | ||
when medically necessary
and prescribed by a physician licensed | ||
to practice medicine in all
of its branches.
Coverage for the | ||
following items shall be subject to deductible, co-payment
and | ||
co-insurance provisions
provided for under the policy or a | ||
durable medical equipment rider to the
policy:
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(1) blood glucose monitors;
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(2) blood glucose monitors for the legally blind;
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(3) cartridges for the legally blind; and
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(4) lancets and lancing devices.
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This subsection does not apply to a group policy of | ||
accident and health
insurance that does not provide a durable | ||
medical equipment benefit.
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(e) Coverage shall be provided for the following | ||
pharmaceuticals and
supplies when
medically necessary and | ||
prescribed by a physician licensed to
practice medicine in all | ||
of its
branches.
Coverage for the following items shall be | ||
subject to the same coverage,
deductible,
co-payment, and | ||
co-insurance
provisions under the policy or a drug rider to the | ||
policy:
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(1) insulin;
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(2) syringes and needles;
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(3) test strips for glucose monitors;
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(4) FDA approved oral agents used to control blood | ||
sugar; and
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(5) glucagon emergency kits.
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This subsection does not apply to a group policy of | ||
accident and health
insurance that does not provide a drug | ||
benefit.
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(f) Coverage shall be provided for regular foot care exams | ||
by a
physician or by a
physician to whom a physician has | ||
referred the patient. Coverage
for regular foot care exams
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shall be subject to the same deductible, co-payment, and | ||
co-insurance
provisions
that apply under the policy for
other | ||
services provided by the same type of provider.
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(g) If authorized by a physician, diabetes self-management
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training may be provided as a part of an office visit, group | ||
setting, or home
visit.
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(h) This Section shall not apply to agreements, contracts, | ||
or policies that
provide coverage for a specified diagnosis or | ||
other limited benefit coverage.
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(Source: P.A. 90-741, eff. 1-1-99.)
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