Illinois § 356z.80

§ 356z.80.

(Text of Section from P.A. 104-1) Sec. 356z.80. Coverage for treatments to slow the progression of Alzheimer's disease and related dementias. (a) 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, 2027 shall provide coverage for all medically necessary diagnostic testing and U.S. Food and Drug Administration-approved treatments or medications prescribed to slow the progression of Alzheimer's disease or another related dementia, in accordance with the U.S. Food and Drug Administration label, as determined by a physician licensed to practice medicine in all its branches. Coverage of U.S. Food and Drug Administration-approved treatments or medications prescribed to slow the progression of Alzheimer's disease or another related dementia pursuant to this Section shall not be subject to step therapy. (b) Nothing in this Section prohibits a group or individual policy of accident and health insurance or managed care plan, by contract, written policy, procedure, or any other agreement or course of conduct, from requiring a pharmacist to effect substitutions of prescription drugs consistent with Section 19.5 of the Pharmacy Practice Act, under which a pharmacist may substitute an interchangeable biologic for a prescribed biologic product, and Section 25 of the Pharmacy Practice Act, under which a pharmacist may select a generic drug determined to be therapeutically equivalent by the United States Food and Drug Administration and in accordance with the Illinois Food, Drug and Cosmetic Act. (c) The coverage required under this Section shall not apply to managed care plans that are under contract with the Department of Healthcare and Family Services. (Source: P.A. 104-1, eff. 6-9-25.) (Text of Section from P.A. 104-42) Sec. 356z.80. Coverage for anesthesia services. (a) 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, 2026 shall provide coverage for medically necessary anesthesia services, regardless of the duration, for any procedure covered by the policy. (b) An individual or group policy of accident and health insurance is prohibited from denying payment or reimbursement for anesthesia services solely because the duration of care exceeded a preset time limit. (Source: P.A. 104-42, eff. 8-1-25.) (Text of Section from P.A. 104-68) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.80. Coverage for hippotherapy and therapeutic riding. (a) As used in this Section, "hippotherapy" means the use by a licensed occupational therapist, physical therapist, or speech-language pathologist, in conjunction with a professional horse handler and a therapy horse, of equine movement to engage sensory, neuromotor, and cognitive systems to promote functional outcomes. (b) A group or individual policy of accident and health insurance that is amended, delivered, issued, or renewed after January 1, 2027 shall provide coverage for medically necessary services, including hippotherapy, that incorporate equine movement as part of a therapeutic intervention. (Source: P.A. 104-68, eff. 1-1-26.) (Text of Section from P.A. 104-73) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.80. Coverage for testing for Klinefelter syndrome. 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, 2027 shall provide coverage for a karyotype test or related hormone testing to diagnose Klinefelter syndrome. (Source: P.A. 104-73, eff. 1-1-26.) (Text of Section from P.A. 104-289) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.80. Laser hair removal. Any group or individual policy of accident or health insurance or a managed care plan that is amended, delivered, issued, or renewed after January 1, 2027 shall provide coverage for medically necessary laser hair removal if the procedure is a prescribed medical treatment in accordance with generally accepted standards of medical care. (Source: P.A. 104-289, eff. 1-1-26.) (Text of Section from P.A. 104-324) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.80. Coverage for complex wheelchair service and repair. (a) As used in this Section: "Complex rehabilitation technology" means a medically necessary complex wheelchair and associated accessories that is individually configured for an individual to meet specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living. "Complex wheelchair" has the meaning given in the Complex Rehabilitation Technology Act. "Qualified complex rehabilitation technology supplier" means a person who meets the requirements of Section 10 of the Complex Rehabilitation Technology Act. "Repair" means the repair or replacement of a deficient, broken, or otherwise malfunctioning part, component, hardware, or software, when the deficient, broken, or otherwise malfunctioning state of such part, component, hardware, or software results in the incapacity of or otherwise diminished capacity for use of a complex rehabilitation technology. (b) 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, 2027 and that provides coverage for complex rehabilitation technology shall not require prior authorization, medical documentation, or proof of continued need to complete medically necessary repairs for consumer-owned complex rehabilitation technology unless: (1) the repairs are covered under a manufacturer's warranty; (2) the cumulative cost of the repairs exceeds 75% of the cost to replace the complex rehabilitation technology; or (3) the complex rehabilitation technology in need of repair is subject to replacement because the age of the complex rehabilitation technology exceeds or is within one year of the expiration of the 5-year reasonable useful life of the complex rehabilitation technology. (c) Notwithstanding subsection (b), a Medicaid managed care plan amended, delivered, issued, or renewed on or after January 1, 2027 and that provides coverage for complex rehabilitation technology shall not require prior authorization, medical documentation, or proof of continued need to complete medically necessary repairs for consumer-owned complex rehabilitation technology under the total value of $1,500. Acceptance or denial of repairs of $1,500 or more must be made within 7 days of request of preauthorization. Documentation of any repairs completed for consumer-owned complex rehabilitation technology shall be maintained by the qualified complex rehabilitation technology supplier conducting the repairs and must be made available to the insurer upon request. (d) 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, 2027 and that provides coverage for a complex rehabilitation technology shall provide coverage for rented complex rehabilitation technology during the time the primary complex rehabilitation technology is under repair consistent with the provisions for consumer-owned complex rehabilitation technology in subsection (b). (e) If, after a post-service review for medical necessity, an insurer finds that any repair of an item not covered at initial issue of the complex wheelchair was not medically necessary, the insurer and owner shall be held harmless for the cost of the repair and the qualified complex rehabilitation technology supplier that conducted the repair shall be liable for the cost of repair. (Source: P.A. 104-324, eff. 1-1-26.) (Text of Section from P.A. 104-379) (This Section may contain text from a Public Act with a delayed effective date) Sec. 356z.80. Coverage for peripheral artery disease screening test. A group or individual plan of accident and health insurance or managed care plan amended, delivered, issued, or renewed on or after January 1, 2027 shall provide medically necessary coverage for a peripheral artery disease screening test for any at-risk individual, as defined by the American College of Cardiology and the American Heart Association's Joint Committee on Clinical Practice Guidelines. (Source: P.A. 104-379, eff. 1-1-26.)