HB5576 EngrossedLRB099 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)(1) The General Assembly hereby finds and declares all
9of the following:
10        (A) Illinois has a long history of expanding timely
11    access to birth control to prevent unintended pregnancy.
12        (B) 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        (C) 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        (D) 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    (2) As used in this subsection (a):
6    "Contraceptive services" includes consultations,
7examinations, procedures, and medical services related to the
8use of contraceptive methods (including natural family
9planning) to prevent an unintended pregnancy.
10    "Medical necessity", for the purposes of this subsection
11(a), includes, but is not limited to, considerations such as
12severity of side effects, differences in permanence and
13reversibility of contraceptive, and ability to adhere to the
14appropriate use of the item or service, as determined by the
15attending 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        (i) they are approved as safe and effective;
22        (ii) 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        (iii) 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        (iv) they are adequately labeled; and
7        (v) they are manufactured in compliance with Current
8    Good Manufacturing Practice regulations.
9    (3) An individual or group policy of accident and health
10insurance amended, delivered, issued, or renewed in this State
11after the effective date of this amendatory Act of the 99th
12General Assembly shall provide coverage for all of the
13following services and contraceptive methods:
14        (A) 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, excluding male
19    condoms. The following apply:
20            (i) 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            (ii) 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            (iii) 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            (iv) This coverage must provide for the dispensing
17        of 12 months' worth of contraception at one time.
18        (B) Voluntary sterilization procedures.
19        (C) Contraceptive services, patient education, and
20    counseling on contraception.
21        (D) 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    (4) Except as otherwise provided in this subsection (a), a



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1policy subject to this subsection (a) shall not impose a
2deductible, coinsurance, copayment, or any other cost-sharing
3requirement on the coverage provided.
4    (5) Except as otherwise authorized under this subsection
5(a), a policy shall not impose any restrictions or delays on
6the coverage required under this subsection (a).
7    (6) If, at any time, the Secretary of the United States
8Department of Health and Human Services, or its successor
9agency, promulgates rules or regulations to be published in the
10Federal Register or publishes a comment in the Federal Register
11or issues an opinion, guidance, or other action that would
12require the State, pursuant to any provision of the Patient
13Protection and Affordable Care Act (Public Law 111148),
14including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
15successor provision, to defray the cost of any coverage
16outlined in this subsection (a), then this subsection (a) is
17inoperative with respect to all coverage outlined in this
18subsection (a) other than that authorized under Section 1902 of
19the Social Security Act, 42 U.S.C. 1396a, and the State shall
20not assume any obligation for the cost of the coverage set
21forth in this subsection (a).
22    (b) This subsection (b) shall become operative if and only
23if subsection (a) becomes inoperative.
24    (a) An individual or group policy of accident and health
25insurance amended, delivered, issued, or renewed in this State
26after the date this subsection (b) becomes operative effective



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



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1or to prohibit the plan or issuer from imposing cost-sharing
2for items or services described in this Section that are
3provided or delivered by an out-of-network provider, unless the
4plan or issuer does not have in its network a provider who is
5able to or is willing to provide the applicable items or
7    (d) Nothing in this Section shall be construed to require
8an insurance company to cover services related to permanent
9sterilization that requires a surgical procedure.
10(Source: P.A. 95-331, eff. 8-21-07.)