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Public Act 103-0639


 

Public Act 0639 103RD GENERAL ASSEMBLY

 


 
Public Act 103-0639
 
SB3414 EnrolledLRB103 38590 RPS 68726 b

    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) A group or individual policy of accident and health
insurance or a managed care plan that is amended, delivered,
issued, or renewed before January 1, 2026 on or after January
1, 2024 shall provide coverage for medically necessary
continuous glucose monitors for individuals who are diagnosed
with any form of diabetes mellitus 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 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 use by individuals, and the choice of
device shall be made based upon the individual's circumstances
and medical needs in consultation with the individual's
medical provider, subject to the terms of the policy.
    (b) 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.
    (c) 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 of a one-month supply
of continuous glucose monitors, including one transmitter if
necessary, as 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; the ordering
    provider is not required to obtain continuing medical
    education in order to prescribe a continuous glucose
    monitor;
        (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) prior authorization is required for a prescription
    of a continuous glucose monitor; once a continuous glucose
    monitor is prescribed, the prior authorization shall be
    approved for a 12-month period.
 
    Section 99. Effective date. This Act takes effect July 1,
2024.

Effective Date: 7/1/2024