Bill Text: IL HB5037 | 2011-2012 | 97th General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code in the provision concerning diabetes self-management training and education. Makes a change to the list of pharmaceuticals and supplies for which coverage shall be provided when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches to include all commercially available insulin preparations, including insulin analog preparations available in a vial or cartridge (now insulin). Effective immediately.

Spectrum: Slight Partisan Bill (Republican 4-2)

Status: (Failed) 2013-01-08 - Session Sine Die [HB5037 Detail]

Download: Illinois-2011-HB5037-Introduced.html

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97TH GENERAL ASSEMBLY State of Illinois 2011 and 2012 HB5037 Introduced 2/7/2012, by Rep. Michael W. Tryon SYNOPSIS AS INTRODUCED:
215 ILCS 5/356w
Amends the Illinois Insurance Code in the provision concerning diabetes self-management training and education. Makes a change to the list of pharmaceuticals and supplies for which coverage shall be provided when medically necessary and prescribed by a physician licensed to practice medicine in all of its branches to include all commercially available insulin preparations, including insulin analog preparations available in a vial or cartridge (now insulin). Effective immediately.
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A BILL FOR
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AN ACT concerning insurance.
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 356w as follows:
(215 ILCS 5/356w)
Sec. 356w. Diabetes self-management training and
education.
(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
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
mellitus.
(b) As used in this Section:
"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

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published by the American Diabetes Association, including
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.
"Medical nutrition therapy" shall have the meaning
ascribed to "medical nutrition care" in the Dietetic and
Nutrition Services Practice Act.
"Physician" means a physician licensed to practice
medicine in all of its branches providing care to the
individual.
"Qualified provider" for an individual that is enrolled in:
(1) a health maintenance organization that uses a
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
licensed network health care professional with expertise
in diabetes management to whom the individual has been
referred by the primary care physician.
(2) an insurance plan means (A) a physician licensed to
practice medicine in all of its branches or (B) a
certified, registered, or licensed health care
professional with expertise in diabetes management to whom

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the individual has been referred by a physician.
(c) Coverage under this Section for diabetes
self-management training, including medical nutrition
education, shall be limited to the following:
(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
date.
(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
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.
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

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required for additional visits beyond those specified in items
(1) and (2) of this subsection.
Coverage under this subsection (c) for diabetes
self-management training shall be subject to the same
deductible, co-payment, and co-insurance provisions that apply
to coverage under the policy for other services provided by the
same type of provider.
(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:
(1) blood glucose monitors;
(2) blood glucose monitors for the legally blind;
(3) cartridges for the legally blind; and
(4) lancets and lancing devices.
This subsection does not apply to a group policy of
accident and health insurance that does not provide a durable
medical equipment benefit.
(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

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policy:
(1) all commercially available insulin preparations,
including insulin analog preparations available in a vial
or cartridge insulin;
(2) syringes and needles;
(3) test strips for glucose monitors;
(4) FDA approved oral agents used to control blood
sugar; and
(5) glucagon emergency kits.
This subsection does not apply to a group policy of
accident and health insurance that does not provide a drug
benefit.
(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
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.
(g) If authorized by a physician, diabetes self-management
training may be provided as a part of an office visit, group
setting, or home visit.
(h) This Section shall not apply to agreements, contracts,
or policies that provide coverage for a specified diagnosis or
other limited benefit coverage.
(Source: P.A. 97-281, eff. 1-1-12.)
Section 99. Effective date. This Act takes effect upon

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becoming law.