(215 ILCS 5/356z.88) (Text of Section from P.A. 104-531) Sec. 356z.88. Durable medical equipment. An individual or group policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2028 that provides coverage for durable medical equipment that is authorized or prescribed by a physician licensed to practice medicine in all its branches shall provide the same level of coverage for durable medical equipment that is authorized or prescribed by a different health care practitioner who lawfully prescribes or orders home medical equipment and services or uses home medical equipment and services to treat the health care practitioner's patients. For the purposes of this Section, "health care practitioner" includes, but is not limited to, a nurse, physical therapist, respiratory therapist, occupational therapist, speech-language pathologist, optometrist, chiropractic physician, or podiatric physician. (Source: P.A. 104-531, eff. 6-26-26.) (Text of Section from P.A. 104-537) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.88. Coverage for prescription hormone therapy. (a) For purposes of this Section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels and the necessary supplies for self-administration. "Prescription hormone therapy" does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists. (b)(1) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 shall provide coverage for up to a 6-month supply of prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a provider within the provider's scope of practice and dispensed at one time for an enrollee by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. If the prescription hormone therapy is a controlled substance, the policy shall provide coverage for the maximum supply allowed under State and federal law to be obtained at one time by the insured. (2) Except as otherwise provided in this Code, this Section does not prohibit an individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2028 from limiting refills that may be obtained in the last quarter of the plan year if a 6-month supply of the prescription hormone therapy has already been dispensed during the plan year. (3) This Section does not require a provider to prescribe, furnish, or dispense 6 months of prescription hormone therapy at one time. (4) To the extent not otherwise prohibited under this Section or State or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under paragraph (1) of this subsection. (5) If an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 delegates responsibilities under this Section to a contracted entity, including a medical group or independent practice association, the delegated entity shall comply with this Section. (c) This Section does not deny or restrict the Department's authority to ensure plan compliance when an individual or group policy of accident and health insurance provides coverage for prescription hormone therapy. (Source: P.A. 104-537, eff. 6-1-27.) (Text of Section from P.A. 104-636) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.88. Hearing care plans and discounted hearing care plans. (a) Definitions. In this Section: "Administrator" means any administrator as defined in Section 370g or 511.101 of this Code. "Cost sharing" has the meaning given to that term in Section 356z.3a of this Code. "Covered items" means items for which reimbursement or capitation from an enrollee's hearing care plan is provided to a hearing instrument professional or for which a reimbursement or discount is provided to an enrollee under a hearing care plan or discounted hearing care plan. "Covered items" includes, but is not limited to, prescription hearing aids, earmolds, domes or inserts, assistive listening devices, and hearing aid supplies and accessories. "Covered items" does not include over-the-counter hearing aids as defined in 21 CFR 800.30(b). "Covered services" means services for which reimbursement or capitation from an enrollee's hearing care plan is provided to a hearing instrument professional or for which a reimbursement or discount is provided to an enrollee under a hearing care plan or discounted hearing care plan. "Discount hearing care benefit" means a hearing care benefit that is offered in a discounted hearing care plan. "Discounted hearing care plan" means a discounted health care services plan, as defined in 50 Ill. Adm. Code 2051.220, that provides discounts for covered items or services. "Enrollee" means any individual enrolled in a hearing care plan or a beneficiary of a discounted hearing care plan. "Excepted benefits" has the meaning given to that term in 42 U.S.C. 300gg-91(c) and federal regulations thereunder. "Funded hearing care benefit" means hearing care benefits that are offered in the enrollee's hearing care plan contract. "Health insurance coverage" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act. "Health insurance issuer" has the meaning given to that term in Section 5 of the Illinois Health Insurance Portability and Accountability Act. "Hearing care benefits" means the covered items or covered services listed or otherwise covered in the contract or plan documents for an enrollee's hearing care plan or discounted hearing care plan. "Hearing care organization" means a health insurance issuer or administrator formed under the laws of this State or another state that issues or administers a hearing care plan or discounted hearing care plan. "Hearing care plan" means any policy, certificate, contract, or other plan of health insurance coverage, whether excepted benefits or any other coverage, that provides coverage for covered items and covered services. "Hearing instrument professional" means a person who is licensed in this State as an audiologist, a hearing instrument dispenser, or a physician. "Manufacturer" means the legal person, including any business entity or other form of organization, that manufactures and distributes hearing aids, earmolds, domes or inserts, assistive listening devices, and hearing aid supplies and accessories. "Noncovered items and services" means items and services that are not funded or discounted by the enrollee's hearing care plan or discounted hearing care plan and where the enrollee is fully responsible for the cost of the item or service. "Prescription hearing aid" means any instrument or device, including an instrument or device dispensed pursuant to a prescription or order, that is designed, intended, or offered for the purpose of improving a person's hearing and any parts, attachments, or accessories, including earmolds. "Prescription hearing aid" does not include batteries, cords, and individual or group auditory training devices and any instrument or device used by a public utility in providing telephone or other communication services. "Routine hearing care services" means services that lack medical necessity, such as pass or fail hearing screenings, that are used to determine the need for additional diagnostic hearing testing. "Subcontractor" means any company, group, or third-party entity, including agents, servants, partially owned or wholly owned subsidiaries, and controlled organizations, that the hearing care organization contracts with to supply items or service for a hearing instrument professional or enrollee to fulfill the benefit plan of a hearing care plan or discounted hearing care plan. (b) No hearing care organization that is an issuer or administrator of a hearing care plan or discounted hearing care plan issued, delivered, amended, or renewed on or after the effective date of this amendatory Act of the 104th General Assembly shall issue or renew a contract that requires a hearing instrument professional, as a condition of participation in the hearing care plan or discounted hearing care plan, to provide items or services to an enrollee at a fee set by the hearing care plan or discounted hearing care plan unless the items and services are covered items or covered services under the hearing care plan or discounted hearing care plan. (c) A hearing instrument professional who chooses not to accept as payment an amount set by a hearing care plan or discounted hearing care plan for items and services that are not covered by the hearing care plan or discounted hearing care plan shall: (1) post, in a conspicuous place, a notice stating the following: "IMPORTANT: This hearing instrument professional does not accept the fee schedule set by your hearing care plan for hearing care items and services that are not covered benefits under your plan, when the item or service is provided prior to the hearing aid fitting, after one year following the initial fitting of the hearing aids, or after all of the allowed service visits are exhausted. In these cases, the hearing instrument professional may charge his or her usual and customary fees for those items and services. This hearing instrument professional will provide you with an estimated cost for each noncovered item or service in accordance with the No Surprises Act."; or (2) provide the information required under paragraph (1) in a document provided by the hearing instrument professional to the patient. (d) Hearing care benefits must be communicated in writing by the hearing care organization to an enrollee, prospective enrollee, and the hearing instrument professional. Covered items and services subject to de minimis reimbursement are not required to be listed in this communication. Noncovered items and noncovered services must be identified in the hearing care plan's marketing materials, contract, and plan documents. (e) No hearing care organization or its officers, directors, agents, and employees may represent a discount hearing care benefit as a funded hearing care benefit. A hearing care organization must clearly list and document, in the schedule of benefits and in marketing materials and plan documents, the specific cost sharing amounts to hearing care benefits provided by both in-network and out-of-network providers of a hearing care plan or, in the case of a discounted hearing care plan, the specific discounted amounts for the discount hearing care benefits provided by preferred providers. (f) A hearing care plan or discounted hearing care plan may provide hearing care benefits that include routine hearing care services and medically necessary diagnostic hearing services in accordance with guidance promulgated by the Centers for Medicare and Medicaid Services. If hearing care benefits or discount hearing care benefits include routine hearing testing for the purpose of fitting or modifying a hearing aid, the hearing instrument professional shall be reimbursed, by the hearing care organization, by the enrollee, or by both, as applicable under the terms of the plan, for the costs of performing the testing regardless of whether the enrollee proceeds with the purchase of a prescription hearing aid. (g) If a hearing care organization is owned or operated, in whole or in part, by a hearing aid manufacturer and that manufacturer offers prescription hearing aids within the hearing care benefits of a hearing care plan or discounted hearing care plan, that hearing care organization must disclose, on its websites for enrollees or potential enrollees, in its marketing communications, and in its benefits or plan documents, its ownership or operational interest and specify which prescription hearing aids are available within the hearing care plan or discounted hearing care plan it issues or administers. (h) The provisions of this Section apply to any subcontractors used by a hearing care organization to supply items or services to a hearing instrument professional. (Source: P.A. 104-636, eff. 1-1-27.) (Text of Section from P.A. 104-710) Sec. 356z.88. Coverage for seizure detection devices. (a) For the purposes of this Section, "seizure detection device" means a monitoring device cleared by the United States Food and Drug Administration, and any related technology, application, service, or subscription supporting the prescribed use of the device, that provides the following: (1) individual monitoring and alert services relating to seizure activity; (2) detection or prediction of seizure activity and transmission of notification of the seizure activity to the individual or a caregiver for appropriate medical response; or (3) collection of data of the seizure activity of the individual that can be used by a health care provider to diagnose or appropriately treat a health care condition that causes the seizure activity. (b) A group or individual plan of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2029 shall provide coverage for medically prescribed seizure detection devices. (c) All seizure detection devices covered under this Section shall be approved for use by individuals, and the choice of device shall be made based upon the individual's circumstances and medical needs in consultation with the individual's medical provider. (d) Any individual who has been prescribed a seizure detection device shall not be required to obtain prior authorization for coverage for a seizure detection device, and coverage shall be continuous once the seizure detection device is prescribed. (e) A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2029 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement of more than $50 on the coverage of a seizure detection device per plan year. The provisions of this subsection do not apply to coverage under this Section to the extent that the coverage would disqualify a high-deductible health plan from eligibility for a health savings account. (Source: P.A. 104-710, eff. 7-31-26.)
Durable medical equipment
215 ILCS 5/356z.88, under Accident And Health Insurance.
215 ILCS 5/356z.88