Illinois 2023-2024 Regular Session

Illinois Senate Bill SB2195 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Public Act 103-0512
2	1		SB2195 EnrolledLRB103 28476 BMS 54857 b SB2195 Enrolled LRB103 28476 BMS 54857 b
3	2		SB2195 Enrolled LRB103 28476 BMS 54857 b
4		-	AN ACT concerning regulation.
5		-	Be it enacted by the People of the State of Illinois,
6		-	represented in the General Assembly:
7		-	Section 5. The Illinois Insurance Code is amended by
8		-	changing Section 356z.18 as follows:
9		-	(215 ILCS 5/356z.18)
10		-	Sec. 356z.18. Prosthetic and customized orthotic devices.
11		-	(a) For the purposes of this Section:
12		-	"Customized orthotic device" means a supportive device for
13		-	the body or a part of the body, the head, neck, or extremities,
14		-	and includes the replacement or repair of the device based on
15		-	the patient's physical condition as medically necessary,
16		-	excluding foot orthotics defined as an in-shoe device designed
17		-	to support the structural components of the foot during
18		-	weight-bearing activities.
19		-	"Licensed provider" means a prosthetist, orthotist, or
20		-	pedorthist licensed to practice in this State.
21		-	"Prosthetic device" means an artificial device to replace,
22		-	in whole or in part, an arm or leg and includes accessories
23		-	essential to the effective use of the device and the
24		-	replacement or repair of the device based on the patient's
25		-	physical condition as medically necessary.
26		-	(b) This amendatory Act of the 96th General Assembly shall
	3	+	1 AN ACT concerning regulation.
	4	+	2 Be it enacted by the People of the State of Illinois,
	5	+	3 represented in the General Assembly:
	6	+	4 Section 5. The Illinois Insurance Code is amended by
	7	+	5 changing Section 356z.18 as follows:
	8	+	6 (215 ILCS 5/356z.18)
	9	+	7 Sec. 356z.18. Prosthetic and customized orthotic devices.
	10	+	8 (a) For the purposes of this Section:
	11	+	9 "Customized orthotic device" means a supportive device for
	12	+	10 the body or a part of the body, the head, neck, or extremities,
	13	+	11 and includes the replacement or repair of the device based on
	14	+	12 the patient's physical condition as medically necessary,
	15	+	13 excluding foot orthotics defined as an in-shoe device designed
	16	+	14 to support the structural components of the foot during
	17	+	15 weight-bearing activities.
	18	+	16 "Licensed provider" means a prosthetist, orthotist, or
	19	+	17 pedorthist licensed to practice in this State.
	20	+	18 "Prosthetic device" means an artificial device to replace,
	21	+	19 in whole or in part, an arm or leg and includes accessories
	22	+	20 essential to the effective use of the device and the
	23	+	21 replacement or repair of the device based on the patient's
	24	+	22 physical condition as medically necessary.
	25	+	23 (b) This amendatory Act of the 96th General Assembly shall
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33		-	provide benefits to any person covered thereunder for expenses
34		-	incurred in obtaining a prosthetic or custom orthotic device
35		-	from any Illinois licensed prosthetist, licensed orthotist, or
36		-	licensed pedorthist as required under the Orthotics,
37		-	Prosthetics, and Pedorthics Practice Act.
38		-	(c) A group or individual major medical policy of accident
39		-	or health insurance or managed care plan or medical, health,
40		-	or hospital service corporation contract that provides
41		-	coverage for prosthetic or custom orthotic care and is
42		-	amended, delivered, issued, or renewed 6 months after the
43		-	effective date of this amendatory Act of the 96th General
44		-	Assembly must provide coverage for prosthetic and orthotic
45		-	devices in accordance with this subsection (c). The coverage
46		-	required under this Section shall be subject to the other
47		-	general exclusions, limitations, and financial requirements of
48		-	the policy, including coordination of benefits, participating
49		-	provider requirements, utilization review of health care
50		-	services, including review of medical necessity, case
51		-	management, and experimental and investigational treatments,
52		-	and other managed care provisions under terms and conditions
53		-	that are no less favorable than the terms and conditions that
54		-	apply to substantially all medical and surgical benefits
55		-	provided under the plan or coverage.
56		-	(d) With respect to an enrollee at any age, in addition to
57		-	coverage of a prosthetic or custom orthotic device required by
58		-	this Section, benefits shall be provided for a prosthetic or
	32	+	SB2195 Enrolled- 2 -LRB103 28476 BMS 54857 b SB2195 Enrolled - 2 - LRB103 28476 BMS 54857 b
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	34	+	1 provide benefits to any person covered thereunder for expenses
	35	+	2 incurred in obtaining a prosthetic or custom orthotic device
	36	+	3 from any Illinois licensed prosthetist, licensed orthotist, or
	37	+	4 licensed pedorthist as required under the Orthotics,
	38	+	5 Prosthetics, and Pedorthics Practice Act.
	39	+	6 (c) A group or individual major medical policy of accident
	40	+	7 or health insurance or managed care plan or medical, health,
	41	+	8 or hospital service corporation contract that provides
	42	+	9 coverage for prosthetic or custom orthotic care and is
	43	+	10 amended, delivered, issued, or renewed 6 months after the
	44	+	11 effective date of this amendatory Act of the 96th General
	45	+	12 Assembly must provide coverage for prosthetic and orthotic
	46	+	13 devices in accordance with this subsection (c). The coverage
	47	+	14 required under this Section shall be subject to the other
	48	+	15 general exclusions, limitations, and financial requirements of
	49	+	16 the policy, including coordination of benefits, participating
	50	+	17 provider requirements, utilization review of health care
	51	+	18 services, including review of medical necessity, case
	52	+	19 management, and experimental and investigational treatments,
	53	+	20 and other managed care provisions under terms and conditions
	54	+	21 that are no less favorable than the terms and conditions that
	55	+	22 apply to substantially all medical and surgical benefits
	56	+	23 provided under the plan or coverage.
	57	+	24 (d) With respect to an enrollee at any age, in addition to
	58	+	25 coverage of a prosthetic or custom orthotic device required by
	59	+	26 this Section, benefits shall be provided for a prosthetic or
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61		-	custom orthotic device determined by the enrollee's provider
62		-	to be the most appropriate model that is medically necessary
63		-	for the enrollee to perform physical activities, as
64		-	applicable, such as running, biking, swimming, and lifting
65		-	weights, and to maximize the enrollee's whole body health and
66		-	strengthen the lower and upper limb function.
67		-	(e) The requirements of this Section do not constitute an
68		-	addition to this State's essential health benefits that
69		-	requires defrayal of costs by this State pursuant to 42 U.S.C.
70		-	18031(d)(3)(B).
71		-	(f) (d) The policy or plan or contract may require prior
72		-	authorization for the prosthetic or orthotic devices in the
73		-	same manner that prior authorization is required for any other
74		-	covered benefit.
75		-	(g) (e) Repairs and replacements of prosthetic and
76		-	orthotic devices are also covered, subject to the co-payments
77		-	and deductibles, unless necessitated by misuse or loss.
78		-	(h) (f) A policy or plan or contract may require that, if
79		-	coverage is provided through a managed care plan, the benefits
80		-	mandated pursuant to this Section shall be covered benefits
81		-	only if the prosthetic or orthotic devices are provided by a
82		-	licensed provider employed by a provider service who contracts
83		-	with or is designated by the carrier, to the extent that the
84		-	carrier provides in-network and out-of-network service, the
85		-	coverage for the prosthetic or orthotic device shall be
86		-	offered no less extensively.
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88	63
89		-	(i) (g) The policy or plan or contract shall also meet
90		-	adequacy requirements as established by the Health Care
91		-	Reimbursement Reform Act of 1985 of the Illinois Insurance
92		-	Code.
93		-	(j) (h) This Section shall not apply to accident only,
94		-	specified disease, short-term hospital or medical, hospital
95		-	confinement indemnity, credit, dental, vision, Medicare
96		-	supplement, long-term care, basic hospital and
97		-	medical-surgical expense coverage, disability income insurance
98		-	coverage, coverage issued as a supplement to liability
99		-	insurance, workers' compensation insurance, or automobile
100		-	medical payment insurance.
101		-	(Source: P.A. 96-833, eff. 6-1-10.)
102		-	Section 99. Effective date. This Act takes effect January
103		-	1, 2025.
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	70	+	1 custom orthotic device determined by the enrollee's provider
	71	+	2 to be the most appropriate model that is medically necessary
	72	+	3 for the enrollee to perform physical activities, as
	73	+	4 applicable, such as running, biking, swimming, and lifting
	74	+	5 weights, and to maximize the enrollee's whole body health and
	75	+	6 strengthen the lower and upper limb function.
	76	+	7 (e) The requirements of this Section do not constitute an
	77	+	8 addition to this State's essential health benefits that
	78	+	9 requires defrayal of costs by this State pursuant to 42 U.S.C.
	79	+	10 18031(d)(3)(B).
	80	+	11 (f) (d) The policy or plan or contract may require prior
	81	+	12 authorization for the prosthetic or orthotic devices in the
	82	+	13 same manner that prior authorization is required for any other
	83	+	14 covered benefit.
	84	+	15 (g) (e) Repairs and replacements of prosthetic and
	85	+	16 orthotic devices are also covered, subject to the co-payments
	86	+	17 and deductibles, unless necessitated by misuse or loss.
	87	+	18 (h) (f) A policy or plan or contract may require that, if
	88	+	19 coverage is provided through a managed care plan, the benefits
	89	+	20 mandated pursuant to this Section shall be covered benefits
	90	+	21 only if the prosthetic or orthotic devices are provided by a
	91	+	22 licensed provider employed by a provider service who contracts
	92	+	23 with or is designated by the carrier, to the extent that the
	93	+	24 carrier provides in-network and out-of-network service, the
	94	+	25 coverage for the prosthetic or orthotic device shall be
	95	+	26 offered no less extensively.
	96	+
	97	+
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	106	+	1 (i) (g) The policy or plan or contract shall also meet
	107	+	2 adequacy requirements as established by the Health Care
	108	+	3 Reimbursement Reform Act of 1985 of the Illinois Insurance
	109	+	4 Code.
	110	+	5 (j) (h) This Section shall not apply to accident only,
	111	+	6 specified disease, short-term hospital or medical, hospital
	112	+	7 confinement indemnity, credit, dental, vision, Medicare
	113	+	8 supplement, long-term care, basic hospital and
	114	+	9 medical-surgical expense coverage, disability income insurance
	115	+	10 coverage, coverage issued as a supplement to liability
	116	+	11 insurance, workers' compensation insurance, or automobile
	117	+	12 medical payment insurance.
	118	+	13 (Source: P.A. 96-833, eff. 6-1-10.)
	119	+	14 Section 99. Effective date. This Act takes effect January
	120	+	15 1, 2025.
	121	+
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	126	+	SB2195 Enrolled - 4 - LRB103 28476 BMS 54857 b