102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB5399

 

Introduced 1/31/2022, by Rep. Norine K. Hammond

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.53 new

    Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with intensity modulated radiation therapy for the same indication if specified conditions are satisfied. Provides standards concerning the aggregate amount chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy. Provides that proton therapy coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract. Defines terms. Effective January 1, 2023.


LRB102 25959 BMS 35349 b

 

 

A BILL FOR

 

HB5399LRB102 25959 BMS 35349 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5adding Section 356z.53 as follows:
 
6    (215 ILCS 5/356z.53 new)
7    Sec. 356z.53. Proton therapy access.
8    (a) As used in this Section:
9    "Aggregate amount" means the total amount paid under an
10individual or group policy of accident and health insurance
11for the applicable radiation treatment delivery current
12procedural terminology codes to deliver a biological effective
13dose.
14    "Biological effective dose" means the total prescribed
15radiation dose delivered in a course of radiation therapy
16treatments to induce tumor cell death.
17    "Current procedural terminology code" means the unique
18numerical designations established by the American Medical
19Association for various medical, surgical, and diagnostic
20services used in billing health care services.
21    "Eligible patient" means a cancer patient who is approved
22for a standard radiation therapy protocol delivered with IMRT
23and prescribed a hypofractionated proton therapy protocol for

 

 

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1the treatment of the same cancer.
2    "Hypofractionated proton therapy protocol" means a cancer
3treatment protocol that involves the delivery of fewer, larger
4radiation therapy treatment doses than a standard radiation
5therapy protocol to deliver a biological effective dose.
6    "Intensity modulated radiation therapy" or "IMRT" means a
7type of conformal radiation therapy that delivers x-ray
8radiation beams of different intensities from many angles for
9the treatment of tumors.
10    "Proton therapy" means the advanced form of radiation
11therapy that utilizes protons as the radiation delivery method
12for the treatment of tumors.
13    "Radiation therapy" means the delivery of a biological
14effective dose with proton therapy, IMRT, brachytherapy,
15stereotactic body radiation therapy, three-dimensional
16conformal radiation therapy, or other forms of therapy using
17radiation.
18    "Registry" means an organized system that uses
19observational study methods to collect uniform clinical data
20to evaluate specified outcomes for a population defined by a
21particular disease and is compliant with the principles
22established by the Registries for Evaluating Patient Outcomes:
23A User's Guide - Third Edition published by the Agency for
24Healthcare Research and Quality of the U.S. Department of
25Health and Human Services.
26    "Standard radiation therapy protocol" means a cancer

 

 

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1treatment protocol that involves the delivery of radiation
2therapy treatment doses over an extended period of time to
3deliver a biological effective dose.
4    "Treatment dose" means the amount of radiation delivered
5in a single treatment or fraction of radiation therapy.
6    (b) An individual or group policy of accident and health
7insurance that is amended, delivered, issued, or renewed on or
8after January 1, 2024 shall cover a medically necessary
9hypofractionated proton therapy protocol to deliver a
10biological effective dose by paying the same aggregate amount
11as would be paid for the delivery of the same biological
12effective dose with a standard radiation therapy protocol
13delivered with IMRT for the same indication if the following
14conditions are satisfied:
15        (1) coverage is provided to an eligible patient who is
16    being treated as part of a clinical trial or registry;
17        (2) the eligible patient is diagnosed with a cancer
18    type or indication that can be treated with a
19    hypofractionated proton therapy protocol; and
20        (3) the radiation oncologist prescribing the
21    hypofractionated proton therapy protocol is board
22    certified or board eligible in the specialty of radiation
23    oncology.
24    (c) If coverage of a hypofractionated proton therapy
25protocol is required pursuant to subsection (b), then:
26        (1) the aggregate amount must be equal to the average

 

 

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1    cost actually paid by an individual or group policy of
2    accident and health insurance for a standard radiation
3    therapy protocol delivered with IMRT required to deliver
4    the prescribed biological effective dose for the
5    particular indication. For the purposes of this paragraph
6    (1), aggregate amounts must be established by reference to
7    the amount paid for a course of IMRT treatment under a
8    standard radiation therapy protocol delivered with IMRT
9    for the indication under the applicable policy; and
10        (2) coverage may not impose an annual deductible,
11    coinsurance, or other cost-sharing limitation that is
12    greater than that required for radiation therapy and other
13    similar benefits within the insurance policy or contract.
14    (d) Notwithstanding any other provision of this Section to
15the contrary, the aggregate amount:
16        (1) reimbursed for the hypofractionated proton therapy
17    protocol must not exceed the average aggregate amount paid
18    by an individual or group policy of accident and health
19    insurance for a course of IMRT treatment under a standard
20    radiation therapy protocol delivered with IMRT to deliver
21    the prescribed biological effective dose for the same
22    indication;
23        (2) chargeable to or payable by an eligible patient
24    for a covered course of hypofractionated proton therapy by
25    an in-network provider must not exceed the aggregate
26    amount that would otherwise be chargeable to or payable by

 

 

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1    the eligible patient for a course of IMRT treatment under
2    a standard radiation therapy protocol delivered with IMRT
3    that is covered by the applicable policy for the delivery
4    of the same biological effective dose by an in-network
5    provider; and
6        (3) chargeable to or payable by an eligible patient
7    for a covered course of hypofractionated proton therapy by
8    an out-of-network provider must not exceed the aggregate
9    amount that would otherwise be chargeable to or payable by
10    the eligible patient for a course of treatment under a
11    standard radiation therapy protocol delivered with IMRT
12    that is covered by the applicable policy for the delivery
13    of the same biological effective dose by an out-of-network
14    provider. However, the patient is not responsible for
15    amounts greater than the allowable maximum charge.
 
16    Section 99. Effective date. This Act takes effect January
171, 2023.