SB3414 EngrossedLRB103 38590 RPS 68726 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.59 as follows:
 
6    (215 ILCS 5/356z.59)
7    Sec. 356z.59. Coverage for continuous glucose monitors.
8    (a) A group or individual policy of accident and health
9insurance or a managed care plan that is amended, delivered,
10issued, or renewed before January 1, 2026 on or after January
111, 2024 shall provide coverage for medically necessary
12continuous glucose monitors for individuals who are diagnosed
13with any form of diabetes mellitus type 1 or type 2 diabetes
14and require insulin for the management of their diabetes. A
15group or individual policy of accident and health insurance or
16a managed care plan that is amended, delivered, issued, or
17renewed on or after January 1, 2026 shall provide coverage for
18continuous glucose monitors, related supplies, and training in
19the use of continuous glucose monitors for any individual if
20the policy is in full alignment with Medicare and the
21following requirements are met:
22        (1) the individual is diagnosed with diabetes
23    mellitus;

 

 

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1        (2) the continuous glucose monitor has been prescribed
2    by a physician licensed under the Medical Practice Act of
3    1987 or a certified nurse practitioner or physician
4    assistant with a collaborative agreement with the
5    physician;
6        (3) the continuous glucose monitor has been prescribed
7    in accordance with the Food and Drug Administration's
8    indications for use;
9        (4) the prescriber has concluded that the individual
10    or individual's caregiver has sufficient training in using
11    the continuous glucose monitor, which may be evidenced by
12    the prescriber having prescribed a continuous glucose
13    monitor, and has attested that the patient will be
14    provided with that training;
15        (5) the individual either:
16            (A) uses insulin for treatment via one or more
17        injections or infusions of insulin per day, and only
18        one injection or infusion of one type of insulin shall
19        be sufficient utilization of insulin to qualify for a
20        continuous glucose monitor under this Section; or
21            (B) has reported a history of problematic
22        hypoglycemia with documentation to the individual's
23        medical provider showing at least one of the
24        following:
25                (i) recurrent hypoglycemic events
26            characterized by an altered mental or physical

 

 

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1            state, despite multiple attempts to adjust
2            medications or modify the diabetes treatment plan,
3            as documented by a medical provider; or
4                (ii) a history of at least one hypoglycemic
5            event characterized by an altered mental or
6            physical state requiring third-party assistance
7            for treatment of hypoglycemia, as documented by
8            the individual's medical provider, which may be
9            self-reported by the individual; third-party
10            assistance shall not, in any event, be deemed to
11            require that the individual had been admitted to a
12            hospital or visited an emergency department; and
13        (6) within 6 months prior to prescribing a continuous
14    glucose monitor, the medical provider prescribing the
15    continuous glucose monitor had an in-person or covered
16    telehealth visit with the individual to evaluate the
17    individual's diabetes control and has determined that the
18    criteria of paragraphs (1) through (5) are met.
19    Notwithstanding any other provision of this Section, to
20qualify for a continuous glucose monitor under this Section,
21an individual is not required to have a diagnosis of
22uncontrolled diabetes; have a history of emergency room visits
23or hospitalizations; or show improved glycemic control.
24    All continuous glucose monitors covered under this Section
25shall be approved for use by individuals, and the choice of
26device shall be made based upon the individual's circumstances

 

 

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1and medical needs in consultation with the individual's
2medical provider, subject to the terms of the policy.
3    (b) Any individual who is diagnosed with diabetes mellitus
4and meets the requirements of this Section shall not be
5required to obtain prior authorization for coverage for a
6continuous glucose monitor, and coverage shall be continuous
7once the continuous glucose monitor is prescribed.
8    (c) A group or individual policy of accident and health
9insurance or a managed care plan that is amended, delivered,
10issued, or renewed on or after January 1, 2026 shall not impose
11a deductible, coinsurance, copayment, or any other
12cost-sharing requirement on the coverage of a one-month supply
13of continuous glucose monitors, including one transmitter if
14necessary, as provided under this Section. The provisions of
15this subsection do not apply to coverage under this Section to
16the extent such coverage would disqualify a high-deductible
17health plan from eligibility for a health savings account
18pursuant to the federal Internal Revenue Code, 26 U.S.C. 23.
19(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)
 
20    Section 10. The Illinois Public Aid Code is amended by
21adding Section 5-16.8a as follows:
 
22    (305 ILCS 5/5-16.8a new)
23    Sec. 5-16.8a. Rules concerning continuous glucose monitor
24coverage. The Department shall adopt rules to implement the

 

 

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1changes made to Section 356z.59 of the Illinois Insurance
2Code, as applied to the medical assistance program. The rules
3shall, at a minimum, provide that:
4        (1) the ordering provider must be a physician licensed
5    under the Medical Practice Act of 1987 or a certified
6    nurse practitioner or physician assistant with a
7    collaborative agreement with the physician;
8        (2) continuous glucose monitors are not required to
9    have an alarm when glucose levels are outside the
10    pre-determined range; the capacity to generate predictive
11    alerts in case of impending hypoglycemia; or the ability
12    to transmit real-time glucose values and alerts to the
13    patient and designated other persons;
14        (3) the beneficiary is not required to need intensive
15    insulin therapy;
16        (4) the beneficiary is not required to have a recent
17    history of emergency room visits or hospitalizations
18    related to hypoglycemia, hyperglycemia, or ketoacidosis;
19        (5) if the beneficiary has gestational diabetes, the
20    beneficiary is not required to have suboptimal glycemic
21    control that is likely to harm the beneficiary or the
22    fetus;
23        (6) if a beneficiary has diabetes mellitus and the
24    beneficiary does not meet the coverage requirements or if
25    the beneficiary is in a population in which continuous
26    glucose monitor usage has not been well-studied, requests

 

 

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1    shall be reviewed, on a case-by-case basis, for medical
2    necessity and approved if appropriate; and
3        (7) the beneficiary is not required to obtain prior
4    authorization for coverage for a continuous glucose
5    monitor, and that coverage is continuous once the
6    continuous glucose monitor is prescribed.
 
7    Section 99. Effective date. This Act takes effect July 1,
82024.