99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB5576

 

Introduced , by Rep. Elaine Nekritz

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.4

    Amends the Illinois Insurance Code. Makes changes to a Section concerning coverage for contraceptives. Provides that that an individual or group health policy shall provide coverage for all contraceptive drugs, devices, and other products approved by the United States Food and Drug Administration, including over-the-counter contraceptive drugs, devices, and products; voluntarily sterilization procedures; contraceptive services, patient education, and counseling on contraception; and follow-up services related to their use. Provides that if the United States Food and Drug Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing; if an individual's attending provider recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing and the plan or issuer must defer to the determination of the attending provider; if a drug, device or product is not covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual, provider or person acting as a patient's authorized representative to ensure coverage without cost sharing; and that coverage must provide for the dispensing of 12 months' worth of contraception at one time. Defines "contraceptive services", "medical necessity", and "therapeutic equivalent version". Removes language prohibiting the provisions from being construed to require an insurance company cover services related to permanent sterilization requiring a surgical procedure.


LRB099 20488 EGJ 45009 b

 

 

A BILL FOR

 

HB5576LRB099 20488 EGJ 45009 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
5changing Section 356z.4 as follows:
 
6    (215 ILCS 5/356z.4)
7    Sec. 356z.4. Coverage for contraceptives.
8    (a) The General Assembly hereby finds and declares all of
9the following:
10        (1) Illinois has a long history of expanding timely
11    access to birth control to prevent unintended pregnancy.
12        (2) The federal Patient Protection and Affordable Care
13    Act includes a contraceptive coverage guarantee as part of
14    a broader requirement for health insurance to cover key
15    preventive care services without out-of-pocket costs for
16    patients.
17        (3) The General Assembly intends to build on existing
18    State and federal law to promote gender equity and women's
19    health and to ensure greater contraceptive coverage equity
20    and timely access to all federal Food and Drug
21    Administration approved methods of birth control for all
22    individuals covered by an individual or group health
23    insurance policy in Illinois.

 

 

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1        (4) Medical management techniques such as denials,
2    step therapy, or prior authorization in public and private
3    health care coverage can impede access to the most
4    effective contraceptive methods.
5    (b) As used in this Section:
6    "Contraceptive services" includes consultations,
7examinations, procedures, and medical services, provided on an
8outpatient basis and related to the use of contraceptive
9methods (including natural family planning) to prevent an
10unintended pregnancy.
11    "Medical necessity" includes, but is not limited to,
12considerations such as severity of side effects, differences in
13permanence and reversibility of contraceptive, and ability to
14adhere to the appropriate use of the item or service, as
15determined by the attending provider.
16    "Therapeutic equivalent version" means drugs, devices, or
17products that can be expected to have the same clinical effect
18and safety profile when administered to patients under the
19conditions specified in the labeling and satisfy the following
20general criteria:
21        (1) they are approved as safe and effective;
22        (2) they are pharmaceutical equivalents in that they
23    (A) contain identical amounts of the same active drug
24    ingredient in the same dosage form and route of
25    administration and (B) meet compendial or other applicable
26    standards of strength, quality, purity, and identity;

 

 

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1        (3) they are bioequivalent in that (A) they do not
2    present a known or potential bioequivalence problem and
3    they meet an acceptable in vitro standard or (B) if they do
4    present such a known or potential problem, they are shown
5    to meet an appropriate bioequivalence standard;
6        (4) they are adequately labeled; and
7        (5) they are manufactured in compliance with Current
8    Good Manufacturing Practice regulations.
9    (c) (a) An individual or group policy of accident and
10health insurance amended, delivered, issued, or renewed in this
11State after the effective date of this amendatory Act of the
1299th General Assembly shall provide coverage for all of the
13following services and contraceptive methods:
14        (1) All contraceptive drugs, devices, and other
15    products approved by the United States Food and Drug
16    Administration. This includes all over-the-counter
17    contraceptive drugs, devices, and products approved by the
18    United States Food and Drug Administration. The following
19    apply:
20            (A) If the United States Food and Drug
21        Administration has approved one or more therapeutic
22        equivalent versions of a contraceptive drug, device,
23        or product, a policy is not required to include all
24        such therapeutic equivalent versions in its formulary,
25        so long as at least one is included and covered without
26        cost-sharing and in accordance with this Section.

 

 

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1            (B) If an individual's attending provider
2        recommends a particular service or item approved by the
3        United States Food and Drug Administration based on a
4        determination of medical necessity with respect to
5        that individual, the plan or issuer must cover that
6        service or item without cost sharing. The plan or
7        issuer must defer to the determination of the attending
8        provider.
9            (C) If a drug, device, or product is not covered,
10        plans and issuers must have an easily accessible,
11        transparent, and sufficiently expedient process that
12        is not unduly burdensome on the individual or a
13        provider or other individual acting as a patient's
14        authorized representative to ensure coverage without
15        cost sharing.
16            (D) This coverage must provide for the dispensing
17        of 12 months' worth of contraception at one time.
18        (2) Voluntary sterilization procedures.
19        (3) Contraceptive services, patient education, and
20    counseling on contraception.
21        (4) Follow-up services related to the drugs, devices,
22    products, and procedures covered under this Section,
23    including, but not limited to, management of side effects,
24    counseling for continued adherence, and device insertion
25    and removal.
26    (d) A policy subject to this Section shall not impose a

 

 

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1deductible, coinsurance, copayment, or any other cost-sharing
2requirement on the coverage provided pursuant to this Section.
3    (e) Except as otherwise authorized under this Section, a
4policy shall not impose any restrictions or delays on the
5coverage required under this Section.
6this amendatory Act of the 93rd General Assembly that provides
7coverage for outpatient services and outpatient prescription
8drugs or devices must provide coverage for the insured and any
9dependent of the insured covered by the policy for all
10outpatient contraceptive services and all outpatient
11contraceptive drugs and devices approved by the Food and Drug
12Administration. Coverage required under this Section may not
13impose any deductible, coinsurance, waiting period, or other
14cost-sharing or limitation that is greater than that required
15for any outpatient service or outpatient prescription drug or
16device otherwise covered by the policy. (b) As used in this
17Section, "outpatient contraceptive service" means
18consultations, examinations, procedures, and medical services,
19provided on an outpatient basis and related to the use of
20contraceptive methods (including natural family planning) to
21prevent an unintended pregnancy.
22    (f) (c) Nothing in this Section shall be construed to
23require an insurance company to cover services related to an
24abortion as the term "abortion" is defined in the Illinois
25Abortion Law of 1975.
26    (d) Nothing in this Section shall be construed to require

 

 

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1an insurance company to cover services related to permanent
2sterilization that requires a surgical procedure.
3(Source: P.A. 95-331, eff. 8-21-07.)