Insurance Coverage For Diabetes
Updated July 2009
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.
More than 23.6 million people in the United States or 7.8% have diabetes mellitus - a serious, lifelong condition. Diabetes is associated with an increased risk for a number of serious, sometimes life-threatening complications. Good diabetes control can help reduce the risk.
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, 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 law does not apply to individual policies, self-insured employers, self-insured union plans, federal government employee plans, or trusts and insurance policies written outside of Illinois. The law does not apply to specified disease contracts such as cancer policies or to limited benefit policies such as dental-only policies.
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 autism, 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:
- Insulin;
- Syringes and needles;
- Test strips for glucose monitors;
- FDA approved oral agents used to control blood sugar; and
- Glucagons 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.
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 http://insurance.illinois.gov