Insurance Coverage For Diabetes
Updated March 2014
Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.
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.
Illinois law (215 ILCS 5/356w) requires insurance companies, HMOs, LHSOs (Limited Health Service Organizations) and Voluntary Health Services Plans to provide coverage for certain diabetes-related services, equipment and supplies in all group policies. Health coverage provided to state, county, and municipal employees (and employees subject to the Schools Code (105 ILCS
5/1-1 et seq.)) must also provide the diabetes benefits.
The state law does not apply to:
- Short-term insurance
- Travel insurance
- Long-term care insurance
- Accident only insurance
- Limited or specified disease insurance
- Blanket policies
- Individual policies
- Self-insured employers
- Self-insured union plans
- Federal government employee plans
- Insurance policies written outside of Illinois
NOTE: For HMOs, the law does apply 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 coverage is required to provide treatment for diabetes, contact the HMO or check your certificate of coverage.
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?
- 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.
- 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
- 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:
- Syringes and needles
- Test strips for glucose monitors;
- FDA approved oral agents used to control blood sugar; and
- Glucagon emergency kits
- 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.
Federal Law – ACA
Federal Law information – Section 2713 of the Federal Affordable Care Act requires group plans (including self-insured plans and employers) and individual health insurance plans and policies to provide coverage of preventive health services without cost-sharing (subject to reasonable medical management technique) when they are delivered by a network provider. These services include coverage for screening for diabetes as recommended by the US Preventive Services Task Force with no cost sharing:
The Federal ACA does not apply to Excepted Benefit Plans as defined 42 U.S.C. 300gg-91.
Excepted Benefits Plans include but are not limited to:
- Short-term limited duration insurance
- Accident or disability income insurance
- Liability insurance, including general liability and auto liability and auto medical payment
- Worker’s compensation or similar insurance
- Credit only insurance
- Coverage for on-site medical clinics
- Long-term care, nursing home care, home health care and community based care
- Medicare supplements
- Specified disease or illness
- Limited dental and vision
- Hospital indemnity or other fixed indemnity insurance
What is Covered
The following diabetes treatments are covered under the Affordable Care Act
- Diabetes screenings for adults with high blood pressure
- Diabetes screening for pregnant women
Information regarding the Affordable Care Act can be found at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Prevention.html
For More Information
Call our Office of Consumer Health Insurance at (877)527-9431
or visit us on our website at http://insurance.illinois.gov