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

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 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 that term in the Dietitian Nutritionist  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 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 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 policy, except as otherwise provided for under Section 356z.41:(1) 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. 101-625, eff. 1-1-21.)