215 ILCS 5/356z.43
2021 Illinois Compiled Statutes|Chapter 215 - INSURANCE|215 ILCS 5/ - Illinois Insurance Code.|Article XX - Accident And Health Insurance

(Text of Section from P.A. 102-34)Sec. 356z.43. (Repealed).  (Source: P.A. 102-34, eff. 6-25-21. Repealed internally, eff. 1-1-22.)(Text of Section from P.A. 102-103)Sec. 356z.43. Coverage for patient care services provided by a pharmacist. 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, 2023 shall provide coverage for health care or patient care services provided by a pharmacist if:(1)   the pharmacist meets the requirements and scope     of practice as set forth in Section 43 of the Pharmacy Practice Act;(2)   the health plan provides coverage for the same     service provided by a licensed physician, an advanced practice registered nurse, or a physician assistant;(3)   the pharmacist is included in the health     benefit plan's network of participating providers; and(4)   a reimbursement has been successfully     negotiated in good faith between the pharmacist and the health plan.   (Source: P.A. 102-103, eff. 1-1-23.)(Text of Section from P.A. 102-203)Sec. 356z.43. Biomarker testing.(a) As used in this Section:"Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. "Biomarker" includes, but is not limited to, gene mutations or protein expression."Biomarker testing" means the analysis of a patient's tissue, blood, or fluid biospecimen for the presence of a biomarker.  "Biomarker testing" includes, but is not limited to, single-analyte tests, multi-plex panel tests, and partial or whole genome sequencing.(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, 2022 shall include coverage for biomarker testing as defined in this Section pursuant to criteria established under subsection (d).(c) Biomarker testing shall be covered and conducted in an efficient manner to provide the most complete range of results to the patient's health care provider without requiring multiple biopsies, biospecimen samples, or other delays or disruptions in patient care.(d) Biomarker testing must be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when the test is supported by medical and scientific evidence, including, but not limited to:(1)   labeled indications for an FDA-approved test or     indicated tests for an FDA-approved drug;(2)   federal Centers for Medicare and Medicaid     Services National Coverage Determinations;(3)   nationally recognized clinical practice     guidelines;(4)   consensus statements;(5)   professional society recommendations;(6)   peer-reviewed literature, biomedical compendia,     and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus, Medline, and MEDLARS database of Health Services Technology Assessment Research; and(7)   peer-reviewed scientific studies published in     or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.(e)   When coverage of biomarker testing for the purpose of diagnosis, treatment, or ongoing monitoring of any medical condition is restricted for use by a group or individual policy of accident and health insurance or managed care plan, the patient and prescribing practitioner shall have access to a clear, readily accessible, and convenient processes to request an exception.  The process shall be made readily accessible on the insurer's website.  (Source: P.A. 102-203, eff. 1-1-22.)(Text of Section from P.A. 102-306)Sec. 356z.43. Coverage for pancreatic cancer screening. 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, 2022 shall provide coverage for  medically necessary pancreatic cancer screening.  (Source: P.A. 102-306, eff. 1-1-22.)(Text of Section from P.A. 102-443)Sec. 356z.43. Colonoscopy coverage.(a)   A group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2022 shall provide coverage for a colonoscopy that is a follow-up exam based on an initial screen where the colonoscopy was determined to be  medically necessary by a physician licensed to practice medicine in all its branches, an advanced practice registered nurse, or a physician assistant.(b)   A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this subsection does not apply to coverage of colonoscopies to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code.  (Source: P.A. 102-443, eff. 1-1-22.)(Text of Section from P.A. 102-530)Sec. 356z.43. A1C testing.(a)   As used in this Section, "A1C testing" means blood sugar level testing used to diagnose prediabetes, type 1 diabetes, and type 2 diabetes and to monitor management of blood sugar levels.(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 A1C testing recommended by a health care provider for prediabetes, type 1 diabetes, and type 2 diabetes in accordance with prediabetes and diabetes risk factors identified by the United States Centers for Disease Control and Prevention.(1)   Risk factors for prediabetes may include, but     are not limited to, being overweight or obese, being aged 35 or older, having an immediate family member with type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.(2)   Risk factors for type 1 diabetes may include,     but are not limited to, family history of diabetes.(3)   Risk factors for type 2 diabetes may include,     but are not limited to, having prediabetes, being overweight or obese, being aged 35 or older, having an immediate family member with type 1 or type 2 diabetes, previous diagnosis of gestational diabetes and being African American, Hispanic or Latino American, American Indian, or Alaska Native.  (Source: P.A. 102-530, eff. 1-1-22.)(Text of Section from P.A. 102-589)Sec. 356z.43. Comprehensive cancer testing.(a)     As used in this Section:"Comprehensive cancer testing" includes, but is not limited to, the following forms of testing:(1)   Targeted cancer gene panels.(2)   Whole-exome genome testing.(3)   Whole-genome sequencing.(4)   RNA sequencing.(5)   Tumor mutation burden."Testing of blood or constitutional tissue for cancer predisposition testing" includes, but is not limited to, the following forms of testing:(1)   Targeted cancer gene panels.(2)   Whole-exome genome testing.(3)   Whole-genome sequencing.(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 the effective date of this amendatory Act of the 102nd General Assembly shall provide coverage for medically necessary comprehensive cancer testing and testing of blood or constitutional tissue for cancer predisposition testing as determined by a physician licensed to practice medicine in all of its branches.  (Source: P.A. 102-589, eff. 1-1-22.)(Text of Section from P.A. 102-642)Sec. 356z.43. Coverage for port-wine stain treatment.(a)   A group or individual policy of accident and health  insurance or managed care plan amended, delivered, issued, or  renewed on or after January 1, 2022 shall provide coverage for  treatment to eliminate or provide maximum  feasible treatment of nevus flammeus, also known as port-wine  stains, including, but not limited to, port-wine stains caused  by Sturge-Weber syndrome. For purposes of this Section, treatment or maximum feasible treatment shall include early intervention treatment, including topical, intralesional, or systemic medical therapy and surgery, and laser treatments approved by the U.S. Food and Drug Administration in children aged 18 years and younger that are intended to prevent functional impairment related to vision function, oral function, inflammation, bleeding, infection, and other medical complications associated with port-wine stains.(b) Coverage for treatment required under this Section shall not include treatment solely for cosmetic purposes.   (Source: P.A. 102-642, eff. 1-1-22.)