HB5382 103RD GENERAL ASSEMBLY

LRB103 39371 RPS 69536 b

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.

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by changing Section 356z.59 as follows:

(215 ILCS 5/356z.59)

Sec. 356z.59. Coverage for continuous glucose monitors.

(a) In this Section, "diabetes mellitus" includes, but is not limited to: type 1 diabetes; type 1.5 diabetes; type 2 diabetes; type 3c diabetes; maturity-onset diabetes of the young; neonatal diabetes; latent autoimmune diabetes of adults; Wolfram Syndrome; Alstrom Syndrome; cystic fibrosis diabetes; gestational diabetes; diabetes caused by the loss of, or permanent damage to, the pancreas; or medication-induced diabetes.

(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, 2024 and before January 1, 2025 shall provide coverage for medically necessary continuous glucose monitors for individuals who are diagnosed with type 1 or type 2 diabetes and require insulin for the management of their diabetes. 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 if the following requirements are met:

(1) the individual is diagnosed with diabetes mellitus;

(2) the continuous glucose monitor has been prescribed by a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician;

(3) the continuous glucose monitor has been prescribed in accordance with the Food and Drug Administration's indications for use;

(4) the prescriber has concluded that the individual or individual's caregiver has sufficient training in using the continuous glucose monitor, which may be evidenced by the prescriber having prescribed a continuous glucose monitor, and has attested that the patient will be provided with that training;

(5) the individual either:

(A) uses insulin for treatment via one or more injections or infusions of insulin per day, and only one injection or infusion of one type of insulin shall be sufficient utilization of insulin to qualify for a continuous glucose monitor under this Section; or

(B) has reported a history of problematic hypoglycemia with documentation to the individual's medical provider showing at least one of the following:

(i) recurrent hypoglycemic events characterized by an altered mental or physical state, despite multiple attempts to adjust medications or modify the diabetes treatment plan, as documented by a medical provider; or

(ii) a history of at least one hypoglycemic event characterized by an altered mental or physical state requiring third-party assistance for treatment of hypoglycemia, as documented by the individual's medical provider, which may be self-reported by the individual; third-party assistance shall not, in any event, be deemed to require that the individual had been admitted to a hospital or visited an emergency department; and

(6) within 6 months prior to prescribing a continuous glucose monitor, the medical provider prescribing the continuous glucose monitor had an in-person or covered telehealth visit with the individual to evaluate the individual's diabetes control and has determined that the criteria of paragraphs (1) through (5) are met.

Notwithstanding any other provision of this Section, to qualify for a continuous glucose monitor under this Section, an individual is not required to have a diagnosis of uncontrolled diabetes; have a history of emergency room visits or hospitalizations; or show improved glycemic control.

All continuous glucose monitors covered under this Section shall be approved for usage by individuals, and the choice of device shall be made based upon the individual's circumstances, preferences, and needs in consultation with the individual's medical provider.

(c) Any individual who is diagnosed with diabetes mellitus and meets the requirements of this Section 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.

(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, 2025 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this Section. The provisions of this subsection do not apply to coverage under this Section to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to the federal Internal Revenue Code, 26 U.S.C. 23.

(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)

Section 10. The Illinois Public Aid Code is amended by adding Section 5-16.8a as follows:

(305 ILCS 5/5-16.8a new)

Sec. 5-16.8a. Rules concerning continuous glucose monitor coverage. The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules shall, at a minimum, provide that:

(1) the ordering provider must be a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician;

(2) continuous glucose monitors are not required to have an alarm when glucose levels are outside the pre-determined range; the capacity to generate predictive alerts in case of impending hypoglycemia; or the ability to transmit real-time glucose values and alerts to the patient and designated other persons;

(3) the beneficiary is not required to need intensive insulin therapy;

(4) the beneficiary is not required to have a recent history of emergency room visits or hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis;

(5) if the beneficiary has gestational diabetes, the beneficiary is not required to have suboptimal glycemic control that is likely to harm the beneficiary or the fetus;

(6) if a beneficiary has diabetes mellitus and the beneficiary does not meet the coverage requirements or if the beneficiary is in a population in which continuous glucose monitor usage has not been well-studied, requests shall be reviewed, on a case-by-case basis, for medical necessity and approved if appropriate; and

(7) the beneficiary is not required to obtain prior authorization for coverage for a continuous glucose monitor, and that coverage is continuous once the continuous glucose monitor is prescribed.

Section 99. Effective date. This Act takes effect July 1, 2024.