Diabetes is a very common condition experienced by many individuals. It is so common that more than 17million individuals in the USA have the mellitus condition, which is a serious condition that stays throughout life. The statistics suggest that every year, there are around 800,000 individuals being diagnosed for diabetes. It is a requirement of the Illinois law that group health care plans including health maintenance organizations (HMOs) and insurance plans to provide cover for various aspects of Type 1, Type 2 and Gestational Diabetes Mellitus.
Who’s to offer Coverage?
Basically HMOs and insurance companies need to cover certain services provided for diabetes. These services include various treatments, equipment and supplies. This law does not require individual policies, self-insured union plans, self-insured employers, trusts and policies outside Illinois to conform to this requirement. However in some cases where the HMO member is a resident of Illinois and the particular HMO has a network in Illinois, this law may be applicable. To clearly establish if your HMO has to conform to this condition or not, contact your HMO directly or refer your benefit booklet. Again, the law may not be applicable to contracts with specified diseases such as Cancer Policies and also policies with limited benefits like Dental only policies.
Who will be covered?
If you want to receive the benefits pointed out within this law, you need to be:
- Covered by a fully insured group HMO or Illinois group insurance policy
- Diagnosed with any of the serious diabetes conditions such as Type 1, Type 2 or Gestational Diabetes Mellitus.
What does coverage include?
This includes education on medical nutrients and must be covered at the same deductible, co-insurance and co-payment levels that are applied by the same type of provider to other services. This kind of self-management training should take place in a group setting as part of an office visit or may be a home visit as well. The cover may be limited to:
- Three visits to a professionally qualified provider, after the initial diagnosis by the physician.
- Two visits to a professionally qualified provider once the patient’s physician decides that patient has experienced significant changes in terms of symptoms and conditions.
- Equipment
Should be necessary and prescribed by the physician and must cover the same deductible, co-insurance and co-payment levels that apply to durable medical equipment rider or durable medical equipment under the policy. Equipment covered under this may include blood glucose monitors, blood glucose monitors for the blind, lancets & lancing devices and cartridges for the blind, etc.
Should be necessary and prescribed by the physician and must cover the same deductible, co-insurance and co-payment levels that apply to prescription drugs under the drug rider or policy. It may include the following supplies: insulin, needles and syringes, test strips used to monitor glucose, oral agents approved by the FDA in order to control blood sugar and glucagon emergency kits.
These regular exams should be performed by a physician and should cover the same deductible, co-insurance and co-payment levels that apply to other services offered by a provider of the same type. |
