103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5382

 

Introduced 2/9/2024, by Rep. Jenn Ladisch Douglass

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.59
305 ILCS 5/5-16.8a new

    Amends the Illinois Insurance Code. Provides that 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, 2025 shall provide coverage for continuous glucose monitors, related supplies, and training in the use of continuous glucose monitors for any individual who is diagnosed with diabetes mellitus and meets other requirements, including that the prescriber had an in-person or covered telehealth visit with the individual to evaluate the individual's diabetes control and has determined that the eligibility criteria is met. Provides that to qualify for a continuous glucose monitor, a patient is not required to have a diagnosis of uncontrolled diabetes; have a history of emergency room visits or hospitalizations; or show improved glycemic control. Provides that an individual who is diagnosed with diabetes mellitus and meets the requirements shall not be required to obtain prior authorization for coverage for a continuous glucose monitor, and coverage shall be continuous once the continuous glucose monitor is prescribed. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall adopt rules to implement the changes made by the amendatory Act. Specifies that the rules shall, at a minimum contain certain provisions concerning the ordering provider, continuous glucose monitors not being required to have certain functionalities, eligibility requirements for a beneficiary, and not requiring prior authorization. Effective July 1, 2024.


LRB103 39371 RPS 69536 b

 

 

A BILL FOR

 

HB5382LRB103 39371 RPS 69536 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) In this Section, "diabetes mellitus" includes, but is
9not limited to: type 1 diabetes; type 1.5 diabetes; type 2
10diabetes; type 3c diabetes; maturity-onset diabetes of the
11young; neonatal diabetes; latent autoimmune diabetes of
12adults; Wolfram Syndrome; Alstrom Syndrome; cystic fibrosis
13diabetes; gestational diabetes; diabetes caused by the loss
14of, or permanent damage to, the pancreas; or
15medication-induced diabetes.
16    (b) A group or individual policy of accident and health
17insurance or a managed care plan that is amended, delivered,
18issued, or renewed on or after January 1, 2024 and before
19January 1, 2025 shall provide coverage for medically necessary
20continuous glucose monitors for individuals who are diagnosed
21with type 1 or type 2 diabetes and require insulin for the
22management of their diabetes. A group or individual policy of
23accident and health insurance or a managed care plan that is

 

 

HB5382- 2 -LRB103 39371 RPS 69536 b

1amended, delivered, issued, or renewed on or after January 1,
22025 shall provide coverage for continuous glucose monitors,
3related supplies, and training in the use of continuous
4glucose monitors for any individual if the following
5requirements are met:
6        (1) the individual is diagnosed with diabetes
7    mellitus;
8        (2) the continuous glucose monitor has been prescribed
9    by a physician licensed under the Medical Practice Act of
10    1987 or a certified nurse practitioner or physician
11    assistant with a collaborative agreement with the
12    physician;
13        (3) the continuous glucose monitor has been prescribed
14    in accordance with the Food and Drug Administration's
15    indications for use;
16        (4) the prescriber has concluded that the individual
17    or individual's caregiver has sufficient training in using
18    the continuous glucose monitor, which may be evidenced by
19    the prescriber having prescribed a continuous glucose
20    monitor, and has attested that the patient will be
21    provided with that training;
22        (5) the individual either:
23            (A) uses insulin for treatment via one or more
24        injections or infusions of insulin per day, and only
25        one injection or infusion of one type of insulin shall
26        be sufficient utilization of insulin to qualify for a

 

 

HB5382- 3 -LRB103 39371 RPS 69536 b

1        continuous glucose monitor under this Section; or
2            (B) has reported a history of problematic
3        hypoglycemia with documentation to the individual's
4        medical provider showing at least one of the
5        following:
6                (i) recurrent hypoglycemic events
7            characterized by an altered mental or physical
8            state, despite multiple attempts to adjust
9            medications or modify the diabetes treatment plan,
10            as documented by a medical provider; or
11                (ii) a history of at least one hypoglycemic
12            event characterized by an altered mental or
13            physical state requiring third-party assistance
14            for treatment of hypoglycemia, as documented by
15            the individual's medical provider, which may be
16            self-reported by the individual; third-party
17            assistance shall not, in any event, be deemed to
18            require that the individual had been admitted to a
19            hospital or visited an emergency department; and
20        (6) within 6 months prior to prescribing a continuous
21    glucose monitor, the medical provider prescribing the
22    continuous glucose monitor had an in-person or covered
23    telehealth visit with the individual to evaluate the
24    individual's diabetes control and has determined that the
25    criteria of paragraphs (1) through (5) are met.
26    Notwithstanding any other provision of this Section, to

 

 

HB5382- 4 -LRB103 39371 RPS 69536 b

1qualify for a continuous glucose monitor under this Section,
2an individual is not required to have a diagnosis of
3uncontrolled diabetes; have a history of emergency room visits
4or hospitalizations; or show improved glycemic control.
5    All continuous glucose monitors covered under this Section
6shall be approved for usage by individuals, and the choice of
7device shall be made based upon the individual's
8circumstances, preferences, and needs in consultation with the
9individual's medical provider.
10    (c) Any individual who is diagnosed with diabetes mellitus
11and meets the requirements of this Section shall not be
12required to obtain prior authorization for coverage for a
13continuous glucose monitor, and coverage shall be continuous
14once the continuous glucose monitor is prescribed.
15    (d) A group or individual policy of accident and health
16insurance or a managed care plan that is amended, delivered,
17issued, or renewed on or after January 1, 2025 shall not impose
18a deductible, coinsurance, copayment, or any other
19cost-sharing requirement on the coverage provided under this
20Section. The provisions of this subsection do not apply to
21coverage under this Section to the extent such coverage would
22disqualify a high-deductible health plan from eligibility for
23a health savings account pursuant to the federal Internal
24Revenue Code, 26 U.S.C. 23.
25(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)
 

 

 

HB5382- 5 -LRB103 39371 RPS 69536 b

1    Section 10. The Illinois Public Aid Code is amended by
2adding Section 5-16.8a as follows:
 
3    (305 ILCS 5/5-16.8a new)
4    Sec. 5-16.8a. Rules concerning continuous glucose monitor
5coverage. The Department shall adopt rules to implement the
6changes made to Section 356z.59 of the Illinois Insurance
7Code, as applied to the medical assistance program. The rules
8shall, at a minimum, provide that:
9        (1) the ordering provider must be a physician licensed
10    under the Medical Practice Act of 1987 or a certified
11    nurse practitioner or physician assistant with a
12    collaborative agreement with the physician;
13        (2) continuous glucose monitors are not required to
14    have an alarm when glucose levels are outside the
15    pre-determined range; the capacity to generate predictive
16    alerts in case of impending hypoglycemia; or the ability
17    to transmit real-time glucose values and alerts to the
18    patient and designated other persons;
19        (3) the beneficiary is not required to need intensive
20    insulin therapy;
21        (4) the beneficiary is not required to have a recent
22    history of emergency room visits or hospitalizations
23    related to hypoglycemia, hyperglycemia, or ketoacidosis;
24        (5) if the beneficiary has gestational diabetes, the
25    beneficiary is not required to have suboptimal glycemic

 

 

HB5382- 6 -LRB103 39371 RPS 69536 b

1    control that is likely to harm the beneficiary or the
2    fetus;
3        (6) if a beneficiary has diabetes mellitus and the
4    beneficiary does not meet the coverage requirements or if
5    the beneficiary is in a population in which continuous
6    glucose monitor usage has not been well-studied, requests
7    shall be reviewed, on a case-by-case basis, for medical
8    necessity and approved if appropriate; and
9        (7) the beneficiary is not required to obtain prior
10    authorization for coverage for a continuous glucose
11    monitor, and that coverage is continuous once the
12    continuous glucose monitor is prescribed.
 
13    Section 99. Effective date. This Act takes effect July 1,
142024.