HB5382ham002 103RD GENERAL ASSEMBLY

Rep. Jenn Ladisch Douglass

Filed: 4/2/2024

10300HB5382ham002 LRB103 39371 RPS 71744 a

AMENDMENT TO HOUSE BILL 5382

AMENDMENT NO. ______. Amend House Bill 5382, AS AMENDED, by replacing everything after the enacting clause with the following:

"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 all forms of diabetes, a chronic condition where the pancreas does not produce insulin or does not produce enough insulin or the body cannot effectively use the insulin it produces.

(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, 2026 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, 2026 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 the coverage shall fully align with the coverage for continuous glucose monitors under Medicare and the eligibility requirements shall be no more restrictive than the eligibility requirements for continuous glucose monitors under Medicare.

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 so long as the continuous glucose monitor has been approved by the United States Food and Drug Administration.

(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, 2026 shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided under this Section for a one-month supply of continuous glucose monitors, including a transmitter if necessary. 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. Continuous glucose monitor coverage.

(a) 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, including the fee-for-service medical assistance program. The rules shall, at a minimum, provide that:

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

(2) the beneficiary is not required to have a diagnosis of uncontrolled diabetes;

(3) the beneficiary is not required to need intensive insulin therapy, to take multiple injections of insulin per day, or to use more than one type of insulin;

(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;

(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; and

(8) continuous glucose monitors covered under this Section shall not be required to have alarms or predictive alerts and shall only be required to have United States Food and Drug Administration approval to be covered.

(b) The fee-for-service medical assistance program shall comply with the requirements of Section 356z.59 of the Illinois Insurance Code.

Section 99. Effective date. This Act takes effect January 1, 2026.".