Sen. Julie A. Morrison

Filed: 4/5/2024

 

 


 

 


 
10300SB3414sam003LRB103 38590 RPS 71896 a

1
AMENDMENT TO SENATE BILL 3414

2    AMENDMENT NO. ______. Amend Senate Bill 3414, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Illinois Insurance Code is amended by
6changing Section 356z.59 as follows:
 
7    (215 ILCS 5/356z.59)
8    Sec. 356z.59. Coverage for continuous glucose monitors.
9    (a) A group or individual policy of accident and health
10insurance or a managed care plan that is amended, delivered,
11issued, or renewed before January 1, 2026 on or after January
121, 2024 shall provide coverage for medically necessary
13continuous glucose monitors for individuals who are diagnosed
14with any form of diabetes mellitus type 1 or type 2 diabetes
15and require insulin for the management of their diabetes. A
16group or individual policy of accident and health insurance or

 

 

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1a managed care plan that is amended, delivered, issued, or
2renewed on or after January 1, 2026 shall provide coverage for
3continuous glucose monitors, related supplies, and training in
4the use of continuous glucose monitors for any individual if
5the policy is in full alignment with Medicare and the
6following requirements are met:
7        (1) the individual is diagnosed with diabetes
8    mellitus;
9        (2) the continuous glucose monitor has been prescribed
10    by a physician licensed under the Medical Practice Act of
11    1987 or a certified nurse practitioner or physician
12    assistant with a collaborative agreement with the
13    physician;
14        (3) the continuous glucose monitor has been prescribed
15    in accordance with the Food and Drug Administration's
16    indications for use;
17        (4) the prescriber has concluded that the individual
18    or individual's caregiver has sufficient training in using
19    the continuous glucose monitor, which may be evidenced by
20    the prescriber having prescribed a continuous glucose
21    monitor, and has attested that the patient will be
22    provided with that training;
23        (5) the individual either:
24            (A) uses insulin for treatment via one or more
25        injections or infusions of insulin per day, and only
26        one injection or infusion of one type of insulin shall

 

 

10300SB3414sam003- 3 -LRB103 38590 RPS 71896 a

1        be sufficient utilization of insulin to qualify for a
2        continuous glucose monitor under this Section; or
3            (B) has reported a history of problematic
4        hypoglycemia with documentation to the individual's
5        medical provider showing at least one of the
6        following:
7                (i) recurrent hypoglycemic events
8            characterized by an altered mental or physical
9            state, despite multiple attempts to adjust
10            medications or modify the diabetes treatment plan,
11            as documented by a medical provider; or
12                (ii) a history of at least one hypoglycemic
13            event characterized by an altered mental or
14            physical state requiring third-party assistance
15            for treatment of hypoglycemia, as documented by
16            the individual's medical provider, which may be
17            self-reported by the individual; third-party
18            assistance shall not, in any event, be deemed to
19            require that the individual had been admitted to a
20            hospital or visited an emergency department; and
21        (6) within 6 months prior to prescribing a continuous
22    glucose monitor, the medical provider prescribing the
23    continuous glucose monitor had an in-person or covered
24    telehealth visit with the individual to evaluate the
25    individual's diabetes control and has determined that the
26    criteria of paragraphs (1) through (5) are met.

 

 

10300SB3414sam003- 4 -LRB103 38590 RPS 71896 a

1    Notwithstanding any other provision of this Section, to
2qualify for a continuous glucose monitor under this Section,
3an individual is not required to have a diagnosis of
4uncontrolled diabetes; have a history of emergency room visits
5or hospitalizations; or show improved glycemic control.
6    All continuous glucose monitors covered under this Section
7shall be approved for use by individuals, and the choice of
8device shall be made based upon the individual's circumstances
9and medical needs in consultation with the individual's
10medical provider, subject to the terms of the policy.
11    (b) Any individual who is diagnosed with diabetes mellitus
12and meets the requirements of this Section shall not be
13required to obtain prior authorization for coverage for a
14continuous glucose monitor, and coverage shall be continuous
15once the continuous glucose monitor is prescribed.
16    (c) A group or individual policy of accident and health
17insurance or a managed care plan that is amended, delivered,
18issued, or renewed on or after January 1, 2026 shall not impose
19a deductible, coinsurance, copayment, or any other
20cost-sharing requirement on the coverage of a one-month supply
21of continuous glucose monitors, including one transmitter if
22necessary, as provided under this Section. The provisions of
23this subsection do not apply to coverage under this Section to
24the extent such coverage would disqualify a high-deductible
25health plan from eligibility for a health savings account
26pursuant to the federal Internal Revenue Code, 26 U.S.C. 23.

 

 

10300SB3414sam003- 5 -LRB103 38590 RPS 71896 a

1(Source: P.A. 102-1093, eff. 1-1-23; 103-154, eff. 6-30-23.)
 
2    Section 10. The Illinois Public Aid Code is amended by
3adding Section 5-16.8a as follows:
 
4    (305 ILCS 5/5-16.8a new)
5    Sec. 5-16.8a. Rules concerning continuous glucose monitor
6coverage. The Department shall adopt rules to implement the
7changes made to Section 356z.59 of the Illinois Insurance
8Code, as applied to the medical assistance program. The rules
9shall, at a minimum, provide that:
10        (1) the ordering provider must be a physician licensed
11    under the Medical Practice Act of 1987 or a certified
12    nurse practitioner or physician assistant with a
13    collaborative agreement with the physician;
14        (2) continuous glucose monitors are not required to
15    have an alarm when glucose levels are outside the
16    pre-determined range; the capacity to generate predictive
17    alerts in case of impending hypoglycemia; or the ability
18    to transmit real-time glucose values and alerts to the
19    patient and designated other persons;
20        (3) the beneficiary is not required to need intensive
21    insulin therapy;
22        (4) the beneficiary is not required to have a recent
23    history of emergency room visits or hospitalizations
24    related to hypoglycemia, hyperglycemia, or ketoacidosis;

 

 

10300SB3414sam003- 6 -LRB103 38590 RPS 71896 a

1        (5) if the beneficiary has gestational diabetes, the
2    beneficiary is not required to have suboptimal glycemic
3    control that is likely to harm the beneficiary or the
4    fetus;
5        (6) if a beneficiary has diabetes mellitus and the
6    beneficiary does not meet the coverage requirements or if
7    the beneficiary is in a population in which continuous
8    glucose monitor usage has not been well-studied, requests
9    shall be reviewed, on a case-by-case basis, for medical
10    necessity and approved if appropriate; and
11        (7) the beneficiary is not required to obtain prior
12    authorization for coverage for a continuous glucose
13    monitor, and that coverage is continuous once the
14    continuous glucose monitor is prescribed.
 
15    Section 99. Effective date. This Act takes effect July 1,
162024.".