Full Text of SB3414 103rd General Assembly
SB3414eng 103RD GENERAL ASSEMBLY | | | SB3414 Engrossed | | LRB103 38590 RPS 68726 b |
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| 1 | | AN ACT concerning regulation. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing 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 | 9 | | insurance or a managed care plan that is amended, delivered, | 10 | | issued, or renewed before January 1, 2026 on or after January | 11 | | 1, 2024 shall provide coverage for medically necessary | 12 | | continuous glucose monitors for individuals who are diagnosed | 13 | | with any form of diabetes mellitus type 1 or type 2 diabetes | 14 | | and require insulin for the management of their diabetes. A | 15 | | group or individual policy of accident and health insurance or | 16 | | a managed care plan that is amended, delivered, issued, or | 17 | | renewed on or after January 1, 2026 shall provide coverage for | 18 | | continuous glucose monitors, related supplies, and training in | 19 | | the use of continuous glucose monitors for any individual if | 20 | | the policy is in full alignment with Medicare and the | 21 | | following 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 | 20 | | qualify for a continuous glucose monitor under this Section, | 21 | | an individual is not required to have a diagnosis of | 22 | | uncontrolled diabetes; have a history of emergency room visits | 23 | | or hospitalizations; or show improved glycemic control. | 24 | | All continuous glucose monitors covered under this Section | 25 | | shall be approved for use by individuals, and the choice of | 26 | | device shall be made based upon the individual's circumstances |
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| 1 | | and medical needs in consultation with the individual's | 2 | | medical provider, subject to the terms of the policy. | 3 | | (b) Any individual who is diagnosed with diabetes mellitus | 4 | | and meets the requirements of this Section shall not be | 5 | | required to obtain prior authorization for coverage for a | 6 | | continuous glucose monitor, and coverage shall be continuous | 7 | | once the continuous glucose monitor is prescribed. | 8 | | (c) A group or individual policy of accident and health | 9 | | insurance or a managed care plan that is amended, delivered, | 10 | | issued, or renewed on or after January 1, 2026 shall not impose | 11 | | a deductible, coinsurance, copayment, or any other | 12 | | cost-sharing requirement on the coverage of a one-month supply | 13 | | of continuous glucose monitors, including one transmitter if | 14 | | necessary, as provided under this Section. The provisions of | 15 | | this subsection do not apply to coverage under this Section to | 16 | | the extent such coverage would disqualify a high-deductible | 17 | | health plan from eligibility for a health savings account | 18 | | pursuant 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 | 21 | | adding Section 5-16.8a as follows: | 22 | | (305 ILCS 5/5-16.8a new) | 23 | | Sec. 5-16.8a. Rules concerning continuous glucose monitor | 24 | | coverage. The Department shall adopt rules to implement the |
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| 1 | | changes made to Section 356z.59 of the Illinois Insurance | 2 | | Code, as applied to the medical assistance program. The rules | 3 | | shall, 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, | 8 | | 2024. |
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