Illinois Insurance Facts 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 patient's physician;
• Two medically necessary visits to a qualified provider when the patient's physician determines that a significant change has occurred in the patient's symptoms or medical condition.
 

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.
 

4. 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 Division of Insurance

Related Information

215 ILCS 5/356w Illinois Compilied Statutes 215 Article XX Accident and Health Insurance (scroll to approximately 1/3 of the way down the page or use find and search for "356w").