103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3036 Introduced , by Rep. Will Guzzardi SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.18 Amends the Accident and Health Article of the Illinois Insurance Code. Provides that with respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. Provides that the requirements of the provisions do not constitute an addition to the State's essential health benefits that requires defrayal of costs by the State pursuant to specified federal law. LRB103 28477 BMS 54858 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3036 Introduced , by Rep. Will Guzzardi SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.18 215 ILCS 5/356z.18 Amends the Accident and Health Article of the Illinois Insurance Code. Provides that with respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. Provides that the requirements of the provisions do not constitute an addition to the State's essential health benefits that requires defrayal of costs by the State pursuant to specified federal law. LRB103 28477 BMS 54858 b LRB103 28477 BMS 54858 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3036 Introduced , by Rep. Will Guzzardi SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.18 215 ILCS 5/356z.18
215 ILCS 5/356z.18
Amends the Accident and Health Article of the Illinois Insurance Code. Provides that with respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. Provides that the requirements of the provisions do not constitute an addition to the State's essential health benefits that requires defrayal of costs by the State pursuant to specified federal law.
LRB103 28477 BMS 54858 b LRB103 28477 BMS 54858 b
LRB103 28477 BMS 54858 b
A BILL FOR
HB3036LRB103 28477 BMS 54858 b HB3036 LRB103 28477 BMS 54858 b
HB3036 LRB103 28477 BMS 54858 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356z.18 as follows:
6 (215 ILCS 5/356z.18)
7 Sec. 356z.18. Prosthetic and customized orthotic devices.
8 (a) For the purposes of this Section:
9 "Customized orthotic device" means a supportive device for
10 the body or a part of the body, the head, neck, or extremities,
11 and includes the replacement or repair of the device based on
12 the patient's physical condition as medically necessary,
13 excluding foot orthotics defined as an in-shoe device designed
14 to support the structural components of the foot during
15 weight-bearing activities.
16 "Licensed provider" means a prosthetist, orthotist, or
17 pedorthist licensed to practice in this State.
18 "Prosthetic device" means an artificial device to replace,
19 in whole or in part, an arm or leg and includes accessories
20 essential to the effective use of the device and the
21 replacement or repair of the device based on the patient's
22 physical condition as medically necessary.
23 (b) This amendatory Act of the 96th General Assembly shall
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3036 Introduced , by Rep. Will Guzzardi SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.18 215 ILCS 5/356z.18
215 ILCS 5/356z.18
Amends the Accident and Health Article of the Illinois Insurance Code. Provides that with respect to an enrollee at any age, in addition to coverage of a prosthetic or custom orthotic device, benefits shall be provided for a prosthetic or custom orthotic device determined by the enrollee's provider to be the most appropriate model that is medically necessary for the enrollee to perform physical activities, as applicable, such as running, biking, swimming, and lifting weights, and to maximize the enrollee's whole body health and strengthen the lower and upper limb function. Provides that the requirements of the provisions do not constitute an addition to the State's essential health benefits that requires defrayal of costs by the State pursuant to specified federal law.
LRB103 28477 BMS 54858 b LRB103 28477 BMS 54858 b
LRB103 28477 BMS 54858 b
A BILL FOR
215 ILCS 5/356z.18
LRB103 28477 BMS 54858 b
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1 provide benefits to any person covered thereunder for expenses
2 incurred in obtaining a prosthetic or custom orthotic device
3 from any Illinois licensed prosthetist, licensed orthotist, or
4 licensed pedorthist as required under the Orthotics,
5 Prosthetics, and Pedorthics Practice Act.
6 (c) A group or individual major medical policy of accident
7 or health insurance or managed care plan or medical, health,
8 or hospital service corporation contract that provides
9 coverage for prosthetic or custom orthotic care and is
10 amended, delivered, issued, or renewed 6 months after the
11 effective date of this amendatory Act of the 96th General
12 Assembly must provide coverage for prosthetic and orthotic
13 devices in accordance with this subsection (c). The coverage
14 required under this Section shall be subject to the other
15 general exclusions, limitations, and financial requirements of
16 the policy, including coordination of benefits, participating
17 provider requirements, utilization review of health care
18 services, including review of medical necessity, case
19 management, and experimental and investigational treatments,
20 and other managed care provisions under terms and conditions
21 that are no less favorable than the terms and conditions that
22 apply to substantially all medical and surgical benefits
23 provided under the plan or coverage.
24 (d) With respect to an enrollee at any age, in addition to
25 coverage of a prosthetic or custom orthotic device required by
26 this Section, benefits shall be provided for a prosthetic or
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1 custom orthotic device determined by the enrollee's provider
2 to be the most appropriate model that is medically necessary
3 for the enrollee to perform physical activities, as
4 applicable, such as running, biking, swimming, and lifting
5 weights, and to maximize the enrollee's whole body health and
6 strengthen the lower and upper limb function.
7 (e) The requirements of this Section do not constitute an
8 addition to this State's essential health benefits that
9 requires defrayal of costs by this State pursuant to 42 U.S.C.
10 18031(d)(3)(B).
11 (f) (d) The policy or plan or contract may require prior
12 authorization for the prosthetic or orthotic devices in the
13 same manner that prior authorization is required for any other
14 covered benefit.
15 (g) (e) Repairs and replacements of prosthetic and
16 orthotic devices are also covered, subject to the co-payments
17 and deductibles, unless necessitated by misuse or loss.
18 (h) (f) A policy or plan or contract may require that, if
19 coverage is provided through a managed care plan, the benefits
20 mandated pursuant to this Section shall be covered benefits
21 only if the prosthetic or orthotic devices are provided by a
22 licensed provider employed by a provider service who contracts
23 with or is designated by the carrier, to the extent that the
24 carrier provides in-network and out-of-network service, the
25 coverage for the prosthetic or orthotic device shall be
26 offered no less extensively.
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1 (i) (g) The policy or plan or contract shall also meet
2 adequacy requirements as established by the Health Care
3 Reimbursement Reform Act of 1985 of the Illinois Insurance
4 Code.
5 (j) (h) This Section shall not apply to accident only,
6 specified disease, short-term hospital or medical, hospital
7 confinement indemnity, credit, dental, vision, Medicare
8 supplement, long-term care, basic hospital and
9 medical-surgical expense coverage, disability income insurance
10 coverage, coverage issued as a supplement to liability
11 insurance, workers' compensation insurance, or automobile
12 medical payment insurance.
13 (Source: P.A. 96-833, eff. 6-1-10.)
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