States have diabetes mellitus–a serious, lifelong condition. diagnosed with diabetes. certain diabetes-related services, equipment and supplies in all …
Illinois Insurance Facts
Illinois Department of Financial and Professional Regulation Division of Insurance
Insurance Coverage For Diabetes
Revised October 2002
Almost everyone knows someone who has diabetes More than 17 million people in the United States have diabetes mellitus–a serious, lifelong condition Each year, about 800,000 people are diagnosed with diabetes Illinois law requires group health care plans, including insurance plans and health maintenance organizations HMOs to provide coverage for outpatient self-management training/education, specified equipment and supplies for treatment of Type 1, Type 2 and Gestational Diabetes Mellitus Here are the basic facts about the law
Who Must Offer the Coverage?
Illinois law 215 ILCS 5/356w requires insurance companies and HMOs to provide coverage for certain diabetes-related services, equipment and supplies in all group policies The law does not apply to individual policies, self-insured employers, self-insured union plans, or trusts and insurance policies written outside of Illinois However, for HMOs, the law does apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of
Illinois and the HMO has established a provider network in Illinois To determine if your HMO provides the coverage required by this law, contact the HMO directly or check your benefit booklet The law does not apply to specified disease contracts such as cancer policies or to limited benefit policies such as dental-only policies
Who is Covered?
To receive benefits required by this law, you must: Be covered by a fully insured Illinois group insurance policy or group HMO contract; Be diagnosed with Type 1, Type 2 or Gestational Diabetes Mellitus
What is Covered?
1 Diabetes self-management training, including medical nutrition education, must be covered at the same deductible, co-payment, and co-insurance levels as those applied to other services provided by the same type of provider Diabetes self-management training may be provided as part of an office visit, in a group setting, or during a home visit Coverage may be limited to: Three medically necessary visits to a qualified provider upon initial diagnosis of diabetes by the patients physician; Two medically necessary visits to a qualified provider when the patients physician determines that a significant change has occurred in
the patients symptoms or medical condition
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2 Diabetic equipment, when medically necessary and prescribed by a physician, must be covered at the same deductible, co-payment, and co-insurance levels as those applied to durable medical equipment under the policy or durable medical equipment rider Coverage for this equipment is only required if the policy provides coverage for durable medical equipment The following equipment is included under this section: Blood glucose monitors; Blood glucose monitors for the legally blind; Cartridges for the legally blind; and Lancets and lancing devices
3 Pharmaceuticals and supplies, when medically necessary and prescribed by a physician, must be covered at the same deductible, co-payment, and co-insurance levels as those applied to prescription drugs under the policy or drug rider Coverage for these pharmaceuticals and supplies is only required if the policy provides coverage for prescription drugs The following pharmaceuticals and supplies must be covered under this section: Insulin; Syringes and needles; Test strips for glucose monitors; FDA approved oral agents used to control blood sugar; and Glucagons emergency kits
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Regular foot care exams by a physician must be covered at the same deductible, co-payment, and co-insurance levels as those applied to other services provided by the same type of provider
For More Information
Call our Consumer Services Section at 312 814-2427 or our Office of Consumer Health Insurance toll free at 877 527-9431 or visit us on our website at wwwinsstateilus
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Source:cchphmo.com
