Full Text of SB3414 103rd General Assembly
SB3414sam003 103RD GENERAL ASSEMBLY | Sen. Julie A. Morrison Filed: 4/5/2024 | | 10300SB3414sam003 | | LRB103 38590 RPS 71896 a |
|
| 1 | | AMENDMENT TO SENATE BILL 3414
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 3414, AS AMENDED, | 3 | | by replacing everything after the enacting clause with the | 4 | | following: | 5 | | "Section 5. The Illinois Insurance Code is amended by | 6 | | changing 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 | 10 | | insurance or a managed care plan that is amended, delivered, | 11 | | issued, or renewed before January 1, 2026 on or after January | 12 | | 1, 2024 shall provide coverage for medically necessary | 13 | | continuous glucose monitors for individuals who are diagnosed | 14 | | with any form of diabetes mellitus type 1 or type 2 diabetes | 15 | | and require insulin for the management of their diabetes. A | 16 | | group or individual policy of accident and health insurance or |
| | | 10300SB3414sam003 | - 2 - | LRB103 38590 RPS 71896 a |
|
| 1 | | a managed care plan that is amended, delivered, issued, or | 2 | | renewed on or after January 1, 2026 shall provide coverage for | 3 | | continuous glucose monitors, related supplies, and training in | 4 | | the use of continuous glucose monitors for any individual if | 5 | | the policy is in full alignment with Medicare and the | 6 | | following 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 | 2 | | qualify for a continuous glucose monitor under this Section, | 3 | | an individual is not required to have a diagnosis of | 4 | | uncontrolled diabetes; have a history of emergency room visits | 5 | | or hospitalizations; or show improved glycemic control. | 6 | | All continuous glucose monitors covered under this Section | 7 | | shall be approved for use by individuals, and the choice of | 8 | | device shall be made based upon the individual's circumstances | 9 | | and medical needs in consultation with the individual's | 10 | | medical provider, subject to the terms of the policy. | 11 | | (b) Any individual who is diagnosed with diabetes mellitus | 12 | | and meets the requirements of this Section shall not be | 13 | | required to obtain prior authorization for coverage for a | 14 | | continuous glucose monitor, and coverage shall be continuous | 15 | | once the continuous glucose monitor is prescribed. | 16 | | (c) 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, 2026 shall not impose | 19 | | a deductible, coinsurance, copayment, or any other | 20 | | cost-sharing requirement on the coverage of a one-month supply | 21 | | of continuous glucose monitors, including one transmitter if | 22 | | necessary, as provided under this Section. The provisions of | 23 | | this subsection do not apply to coverage under this Section to | 24 | | the extent such coverage would disqualify a high-deductible | 25 | | health plan from eligibility for a health savings account | 26 | | pursuant 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 | 3 | | adding Section 5-16.8a as follows: | 4 | | (305 ILCS 5/5-16.8a new) | 5 | | Sec. 5-16.8a. Rules concerning continuous glucose monitor | 6 | | coverage. The Department shall adopt rules to implement the | 7 | | changes made to Section 356z.59 of the Illinois Insurance | 8 | | Code, as applied to the medical assistance program. The rules | 9 | | shall, 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, | 16 | | 2024.". |
|