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| Public Act 103-0639 | ||||
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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. | ||