Illinois-2023-HB5382-Introduced

103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB5382

Introduced , 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

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LRB103 39371 RPS 69536 b

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) In this Section, "diabetes mellitus" includes, but is

9 not limited to: type 1 diabetes; type 1.5 diabetes; type 2

10 diabetes; type 3c diabetes; maturity-onset diabetes of the

11 young; neonatal diabetes; latent autoimmune diabetes of

12 adults; Wolfram Syndrome; Alstrom Syndrome; cystic fibrosis

13 diabetes; gestational diabetes; diabetes caused by the loss

14 of, or permanent damage to, the pancreas; or

15 medication-induced diabetes.

16 (b) A group or individual policy of accident and health

17 insurance or a managed care plan that is amended, delivered,

18 issued, or renewed on or after January 1, 2024 and before

19 January 1, 2025 shall provide coverage for medically necessary

20 continuous glucose monitors for individuals who are diagnosed

21 with type 1 or type 2 diabetes and require insulin for the

22 management of their diabetes. A group or individual policy of

23 accident and health insurance or a managed care plan that is

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1 amended, delivered, issued, or renewed on or after January 1,

2 2025 shall provide coverage for continuous glucose monitors,

3 related supplies, and training in the use of continuous

4 glucose monitors for any individual if the following

5 requirements 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

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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

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1 qualify for a continuous glucose monitor under this Section,

2 an individual is not required to have a diagnosis of

3 uncontrolled diabetes; have a history of emergency room visits

4 or hospitalizations; or show improved glycemic control.

5 All continuous glucose monitors covered under this Section

6 shall be approved for usage by individuals, and the choice of

7 device shall be made based upon the individual's

8 circumstances, preferences, and needs in consultation with the

9 individual's medical provider.

10 (c) Any individual who is diagnosed with diabetes mellitus

11 and meets the requirements of this Section shall not be

12 required to obtain prior authorization for coverage for a

13 continuous glucose monitor, and coverage shall be continuous

14 once the continuous glucose monitor is prescribed.

15 (d) A group or individual policy of accident and health

16 insurance or a managed care plan that is amended, delivered,

17 issued, or renewed on or after January 1, 2025 shall not impose

18 a deductible, coinsurance, copayment, or any other

19 cost-sharing requirement on the coverage provided under this

20 Section. The provisions of this subsection do not apply to

21 coverage under this Section to the extent such coverage would

22 disqualify a high-deductible health plan from eligibility for

23 a health savings account pursuant to the federal Internal

24 Revenue Code, 26 U.S.C. 23.

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

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1 Section 10. The Illinois Public Aid Code is amended by

2 adding Section 5-16.8a as follows:

3 (305 ILCS 5/5-16.8a new)

4 Sec. 5-16.8a. Rules concerning continuous glucose monitor

5 coverage. The Department shall adopt rules to implement the

6 changes made to Section 356z.59 of the Illinois Insurance

7 Code, as applied to the medical assistance program. The rules

8 shall, 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

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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.