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| [ Engrossed ] | [ House Amendment 001 ] |
90_HB3339
20 ILCS 1405/56.3 new
215 ILCS 5/356w new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 130/3009 from Ch. 73, par. 1503-9
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, Health Maintenance
Organization Act, Limited Health Service Organization Act,
and Voluntary Health Services Plans Act. Provides that
health benefit coverage under those Acts must include
coverage for patient care provided pursuant to
investigational cancer treatments. Repeals the coverage
requirement January 1, 2002. Defines terms. Amends the Civil
Administrative Code of Illinois to require the Department of
Insurance to conduct a study of the costs and benefits of the
coverage requirements. Effective January 1, 1999.
LRB9010497JSpk
LRB9010497JSpk
1 AN ACT concerning benefits for certain health treatments.
2 WHEREAS, It is the intent of the General Assembly to
3 recognize that cancer clinical trials are designed to compare
4 the effectiveness of the standard medical treatment with a
5 new therapy that researchers believe will prove more
6 effective, based on scientific evidence and that such
7 research provides the foundation for improved patient care
8 and decreased health care costs; and
9 WHEREAS, It is the intent of the General Assembly to
10 recognize that cancer clinical trials involve a rigorously
11 developed clinical protocol that includes goals, rationale
12 and background, criteria for patient selection, specific
13 directions for administering therapy and monitoring patients,
14 definition of quantitative measures for determining treatment
15 response, and methods for documenting and treating adverse
16 reactions; and
17 WHEREAS, It is the intent of the General Assembly to
18 recognize that virtually every major breakthrough for current
19 standard medical treatment has been developed through the
20 clinical trial system; and
21 WHEREAS, It is the intent of the General Assembly to
22 acknowledge that cancer clinical trials can be cost neutral
23 in comparison to the standard therapy; therefore
24 Be it enacted by the People of the State of Illinois,
25 represented in the General Assembly:
26 Section 5. The Civil Administrative Code of Illinois is
27 amended by adding Section 56.3 as follows:
28 (20 ILCS 1405/56.3 new)
29 Sec. 56.3. Investigational cancer treatments; study.
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1 (a) The Department of Insurance shall conduct an
2 analysis and study of costs and benefits derived from the
3 implementation of the coverage requirements for
4 investigational cancer treatments established under Section
5 356w of the Illinois Insurance Code. The study shall cover
6 the years 1999 and 2000. The study shall include an analysis
7 of the effect of the coverage requirements on the cost of
8 insurance and health care, the results of the treatments to
9 patients, the mortality rate among cancer patients, any
10 improvements in care of patients, and any improvements in the
11 quality of life of patients.
12 (b) The Department shall report the results of its study
13 to the General Assembly and the Governor on or before April
14 30, 2001.
15 Section 10. The Illinois Insurance Code is amended by
16 adding Section 356w as follows:
17 (215 ILCS 5/356w new)
18 Sec. 356w. Coverage for investigational cancer
19 treatments.
20 (a) An individual or group policy of accident and health
21 insurance issued, delivered, amended, or renewed in this
22 State after the effective date of this amendatory Act of 1998
23 must provide coverage for patient care of insureds, when
24 medically appropriate, to participate in an approved research
25 trial and shall provide coverage for the patient care
26 provided pursuant to investigational cancer treatments as
27 provided in subsection (b).
28 (b) Coverage must be included for an item or service
29 that would otherwise be covered, subject to the limitations
30 and cost sharing requirements applicable to the item or
31 service, when that item or service is provided to an insured
32 in the course of an investigational cancer treatment if:
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1 (1) the treatment is a qualifying cancer
2 investigational treatment; and
3 (2) the cancer treatment is administered as part of
4 the medical management of a life-threatening disease,
5 disorder, or health condition.
6 Coverage must be included for an item or service when
7 that item or service is required to provide patient care
8 pursuant to the design of a research trial, except those
9 items or services normally paid for by other funding sources,
10 such as the costs of certain investigational agents, the
11 costs of any nonhealth services that might be required for a
12 person to receive cancer treatment, and the costs of managing
13 the research; items or services subject to this exception may
14 be covered in addition to patient care at the discretion of
15 the health plan.
16 (c) For purposes of this Section, (A) "qualifying
17 investigational cancer treatment" means a treatment (i) the
18 effectiveness of which has not been determined and (ii) that
19 is under clinical investigation as part of an approved cancer
20 research trial in Phase II, Phase III, or Phase IV of
21 investigation and (B) "approved cancer research trial" means
22 (i) a cancer research trial approved by the U.S. Secretary of
23 Health and Human Services, the Director of the National
24 Institutes of Health, the Commissioner of the Food and Drug
25 Administration (through an investigational new drug exemption
26 under Section 505(1) of the federal Food, Drug and Cosmetic
27 Act or an investigational device exemption under Section
28 520(g) of that Act), the Secretary of Veterans Affairs, the
29 Secretary of Defense, or a qualified nongovernmental cancer
30 research entity as defined in guidelines of the National
31 Institutes of Health or (ii) a peer-reviewed and approved
32 cancer research program, as defined by the U.S. Secretary of
33 Health and Human Services, conducted for the primary purpose
34 of determining whether or not a cancer treatment is safe or
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1 efficacious or has any other characteristic of a cancer
2 treatment that must be demonstrated in order for the cancer
3 treatment to be medically necessary or appropriate.
4 (d) This Section is repealed on January 1, 2002.
5 Section 15. The Health Maintenance Organization Act is
6 amended by changing Section 5-3 as follows:
7 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
8 (Text of Section before amendment by P.A. 90-372)
9 Sec. 5-3. Insurance Code provisions.
10 (a) Health Maintenance Organizations shall be subject to
11 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
12 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
13 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
14 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
15 paragraph (c) of subsection (2) of Section 367, and Articles
16 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
17 Illinois Insurance Code.
18 (b) For purposes of the Illinois Insurance Code, except
19 for Articles XIII and XIII 1/2, Health Maintenance
20 Organizations in the following categories are deemed to be
21 "domestic companies":
22 (1) a corporation authorized under the Medical
23 Service Plan Act, the Dental Service Plan Act, the
24 Pharmaceutical Service Plan Act, or the Voluntary Health
25 Services Plans Plan Act, or the Nonprofit Health Care
26 Service Plan Act;
27 (2) a corporation organized under the laws of this
28 State; or
29 (3) a corporation organized under the laws of
30 another state, 30% or more of the enrollees of which are
31 residents of this State, except a corporation subject to
32 substantially the same requirements in its state of
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1 organization as is a "domestic company" under Article
2 VIII 1/2 of the Illinois Insurance Code.
3 (c) In considering the merger, consolidation, or other
4 acquisition of control of a Health Maintenance Organization
5 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
6 (1) the Director shall give primary consideration
7 to the continuation of benefits to enrollees and the
8 financial conditions of the acquired Health Maintenance
9 Organization after the merger, consolidation, or other
10 acquisition of control takes effect;
11 (2)(i) the criteria specified in subsection (1)(b)
12 of Section 131.8 of the Illinois Insurance Code shall not
13 apply and (ii) the Director, in making his determination
14 with respect to the merger, consolidation, or other
15 acquisition of control, need not take into account the
16 effect on competition of the merger, consolidation, or
17 other acquisition of control;
18 (3) the Director shall have the power to require
19 the following information:
20 (A) certification by an independent actuary of
21 the adequacy of the reserves of the Health
22 Maintenance Organization sought to be acquired;
23 (B) pro forma financial statements reflecting
24 the combined balance sheets of the acquiring company
25 and the Health Maintenance Organization sought to be
26 acquired as of the end of the preceding year and as
27 of a date 90 days prior to the acquisition, as well
28 as pro forma financial statements reflecting
29 projected combined operation for a period of 2
30 years;
31 (C) a pro forma business plan detailing an
32 acquiring party's plans with respect to the
33 operation of the Health Maintenance Organization
34 sought to be acquired for a period of not less than
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1 3 years; and
2 (D) such other information as the Director
3 shall require.
4 (d) The provisions of Article VIII 1/2 of the Illinois
5 Insurance Code and this Section 5-3 shall apply to the sale
6 by any health maintenance organization of greater than 10% of
7 its enrollee population (including without limitation the
8 health maintenance organization's right, title, and interest
9 in and to its health care certificates).
10 (e) In considering any management contract or service
11 agreement subject to Section 141.1 of the Illinois Insurance
12 Code, the Director (i) shall, in addition to the criteria
13 specified in Section 141.2 of the Illinois Insurance Code,
14 take into account the effect of the management contract or
15 service agreement on the continuation of benefits to
16 enrollees and the financial condition of the health
17 maintenance organization to be managed or serviced, and (ii)
18 need not take into account the effect of the management
19 contract or service agreement on competition.
20 (f) Except for small employer groups as defined in the
21 Small Employer Rating, Renewability and Portability Health
22 Insurance Act and except for medicare supplement policies as
23 defined in Section 363 of the Illinois Insurance Code, a
24 Health Maintenance Organization may by contract agree with a
25 group or other enrollment unit to effect refunds or charge
26 additional premiums under the following terms and conditions:
27 (i) the amount of, and other terms and conditions
28 with respect to, the refund or additional premium are set
29 forth in the group or enrollment unit contract agreed in
30 advance of the period for which a refund is to be paid or
31 additional premium is to be charged (which period shall
32 not be less than one year); and
33 (ii) the amount of the refund or additional premium
34 shall not exceed 20% of the Health Maintenance
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1 Organization's profitable or unprofitable experience with
2 respect to the group or other enrollment unit for the
3 period (and, for purposes of a refund or additional
4 premium, the profitable or unprofitable experience shall
5 be calculated taking into account a pro rata share of the
6 Health Maintenance Organization's administrative and
7 marketing expenses, but shall not include any refund to
8 be made or additional premium to be paid pursuant to this
9 subsection (f)). The Health Maintenance Organization and
10 the group or enrollment unit may agree that the
11 profitable or unprofitable experience may be calculated
12 taking into account the refund period and the immediately
13 preceding 2 plan years.
14 The Health Maintenance Organization shall include a
15 statement in the evidence of coverage issued to each enrollee
16 describing the possibility of a refund or additional premium,
17 and upon request of any group or enrollment unit, provide to
18 the group or enrollment unit a description of the method used
19 to calculate (1) the Health Maintenance Organization's
20 profitable experience with respect to the group or enrollment
21 unit and the resulting refund to the group or enrollment unit
22 or (2) the Health Maintenance Organization's unprofitable
23 experience with respect to the group or enrollment unit and
24 the resulting additional premium to be paid by the group or
25 enrollment unit.
26 In no event shall the Illinois Health Maintenance
27 Organization Guaranty Association be liable to pay any
28 contractual obligation of an insolvent organization to pay
29 any refund authorized under this Section.
30 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
31 90-177, eff. 7-23-97; revised 11-21-97.)
32 (Text of Section after amendment by P.A. 90-372)
33 Sec. 5-3. Insurance Code provisions.
34 (a) Health Maintenance Organizations shall be subject to
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1 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
2 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
3 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
4 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
5 paragraph (c) of subsection (2) of Section 367, and Articles
6 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
7 Illinois Insurance Code.
8 (b) For purposes of the Illinois Insurance Code, except
9 for Articles XIII and XIII 1/2, Health Maintenance
10 Organizations in the following categories are deemed to be
11 "domestic companies":
12 (1) a corporation authorized under the Medical
13 Service Plan Act, the Dental Service Plan Act or, the
14 Voluntary Health Services Plans Plan Act, or the
15 Nonprofit Health Care Service Plan Act;
16 (2) a corporation organized under the laws of this
17 State; or
18 (3) a corporation organized under the laws of
19 another state, 30% or more of the enrollees of which are
20 residents of this State, except a corporation subject to
21 substantially the same requirements in its state of
22 organization as is a "domestic company" under Article
23 VIII 1/2 of the Illinois Insurance Code.
24 (c) In considering the merger, consolidation, or other
25 acquisition of control of a Health Maintenance Organization
26 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
27 (1) the Director shall give primary consideration
28 to the continuation of benefits to enrollees and the
29 financial conditions of the acquired Health Maintenance
30 Organization after the merger, consolidation, or other
31 acquisition of control takes effect;
32 (2)(i) the criteria specified in subsection (1)(b)
33 of Section 131.8 of the Illinois Insurance Code shall not
34 apply and (ii) the Director, in making his determination
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1 with respect to the merger, consolidation, or other
2 acquisition of control, need not take into account the
3 effect on competition of the merger, consolidation, or
4 other acquisition of control;
5 (3) the Director shall have the power to require
6 the following information:
7 (A) certification by an independent actuary of
8 the adequacy of the reserves of the Health
9 Maintenance Organization sought to be acquired;
10 (B) pro forma financial statements reflecting
11 the combined balance sheets of the acquiring company
12 and the Health Maintenance Organization sought to be
13 acquired as of the end of the preceding year and as
14 of a date 90 days prior to the acquisition, as well
15 as pro forma financial statements reflecting
16 projected combined operation for a period of 2
17 years;
18 (C) a pro forma business plan detailing an
19 acquiring party's plans with respect to the
20 operation of the Health Maintenance Organization
21 sought to be acquired for a period of not less than
22 3 years; and
23 (D) such other information as the Director
24 shall require.
25 (d) The provisions of Article VIII 1/2 of the Illinois
26 Insurance Code and this Section 5-3 shall apply to the sale
27 by any health maintenance organization of greater than 10% of
28 its enrollee population (including without limitation the
29 health maintenance organization's right, title, and interest
30 in and to its health care certificates).
31 (e) In considering any management contract or service
32 agreement subject to Section 141.1 of the Illinois Insurance
33 Code, the Director (i) shall, in addition to the criteria
34 specified in Section 141.2 of the Illinois Insurance Code,
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1 take into account the effect of the management contract or
2 service agreement on the continuation of benefits to
3 enrollees and the financial condition of the health
4 maintenance organization to be managed or serviced, and (ii)
5 need not take into account the effect of the management
6 contract or service agreement on competition.
7 (f) Except for small employer groups as defined in the
8 Small Employer Rating, Renewability and Portability Health
9 Insurance Act and except for medicare supplement policies as
10 defined in Section 363 of the Illinois Insurance Code, a
11 Health Maintenance Organization may by contract agree with a
12 group or other enrollment unit to effect refunds or charge
13 additional premiums under the following terms and conditions:
14 (i) the amount of, and other terms and conditions
15 with respect to, the refund or additional premium are set
16 forth in the group or enrollment unit contract agreed in
17 advance of the period for which a refund is to be paid or
18 additional premium is to be charged (which period shall
19 not be less than one year); and
20 (ii) the amount of the refund or additional premium
21 shall not exceed 20% of the Health Maintenance
22 Organization's profitable or unprofitable experience with
23 respect to the group or other enrollment unit for the
24 period (and, for purposes of a refund or additional
25 premium, the profitable or unprofitable experience shall
26 be calculated taking into account a pro rata share of the
27 Health Maintenance Organization's administrative and
28 marketing expenses, but shall not include any refund to
29 be made or additional premium to be paid pursuant to this
30 subsection (f)). The Health Maintenance Organization and
31 the group or enrollment unit may agree that the
32 profitable or unprofitable experience may be calculated
33 taking into account the refund period and the immediately
34 preceding 2 plan years.
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1 The Health Maintenance Organization shall include a
2 statement in the evidence of coverage issued to each enrollee
3 describing the possibility of a refund or additional premium,
4 and upon request of any group or enrollment unit, provide to
5 the group or enrollment unit a description of the method used
6 to calculate (1) the Health Maintenance Organization's
7 profitable experience with respect to the group or enrollment
8 unit and the resulting refund to the group or enrollment unit
9 or (2) the Health Maintenance Organization's unprofitable
10 experience with respect to the group or enrollment unit and
11 the resulting additional premium to be paid by the group or
12 enrollment unit.
13 In no event shall the Illinois Health Maintenance
14 Organization Guaranty Association be liable to pay any
15 contractual obligation of an insolvent organization to pay
16 any refund authorized under this Section.
17 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
18 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
19 Section 20. The Limited Health Service Organization Act
20 is amended by changing Section 3009 as follows:
21 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
22 Sec. 3009. Point-of-service limited health service
23 contracts.
24 (a) An LHSO that offers a POS contract:
25 (1) shall include as in-plan covered services all
26 services required by law to be provided by an LHSO;
27 (2) shall provide incentives, which shall include
28 financial incentives, for enrollees to use in-plan
29 covered services;
30 (3) shall not offer services out-of-plan without
31 providing those services on an in-plan basis;
32 (4) may limit or exclude specific types of services
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1 from coverage when obtained out-of-plan;
2 (5) may include annual out-of-pocket limits and
3 lifetime maximum benefits allowances for out-of-plan
4 services that are separate from any limits or allowances
5 applied to in-plan services;
6 (6) shall include an annual maximum benefit
7 allowance not to exceed $2,500 per year that is separate
8 from any limits or allowances applied to in-plan
9 services;
10 (7) may limit the groups to which a POS product is
11 offered, however, if a POS product is offered to a group,
12 then it must be offered to all eligible members of that
13 group, when an LHSO provider is available;
14 (8) shall not consider emergency services,
15 authorized referral services, or non-routine services
16 obtained out of the service area to be POS services; and
17 (9) may treat as out-of-plan services those
18 services that an enrollee obtains from a participating
19 provider, but for which the proper authorization was not
20 given by the LHSO.
21 (b) An LHSO offering a POS contract shall be subject to
22 the following limitations:
23 (1) The LHSO shall not expend in any calendar
24 quarter more than 20% of its total limited health
25 services expenditures for all its members for out-of-plan
26 covered services.
27 (2) If the amount specified in paragraph (1) is
28 exceeded by 2% in a quarter, the LHSO shall effect
29 compliance with paragraph (1) by the end of the following
30 quarter.
31 (3) If compliance with the amount specified in
32 paragraph (1) is not demonstrated in the LHSO's next
33 quarterly report, the LHSO may not offer the POS contract
34 to new groups or include the POS option in the renewal of
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1 an existing group until compliance with the amount
2 specified in paragraph (1) is demonstrated or otherwise
3 allowed by the Director.
4 (4) Any LHSO failing, without just cause, to comply
5 with the provisions of this subsection shall be required,
6 after notice and hearing, to pay a penalty of $250 for
7 each day out of compliance, to be recovered by the
8 Director of Insurance. Any penalty recovered shall be
9 paid into the General Revenue Fund. The Director may
10 reduce the penalty if the LHSO demonstrates to the
11 Director that the imposition of the penalty would
12 constitute a financial hardship to the LHSO.
13 (c) Any LHSO that offers a POS product shall:
14 (1) File a quarterly financial statement detailing
15 compliance with the requirements of subsection (b).
16 (2) Track out-of-plan POS utilization separately
17 from in-plan or non-POS out-of-plan emergency care,
18 referral care, and urgent care out of the service area
19 utilization.
20 (3) Record out-of-plan utilization in a manner that
21 will permit such utilization and cost reporting as the
22 Director may, by regulation, require.
23 (4) Demonstrate to the Director's satisfaction that
24 the LHSO has the fiscal, administrative, and marketing
25 capacity to control its POS enrollment, utilization, and
26 costs so as not to jeopardize the financial security of
27 the LHSO.
28 (5) Maintain the deposit required by subsection (b)
29 of Section 2006 in addition to any other deposit required
30 under this Act.
31 (d) An LHSO shall not issue a POS contract until it has
32 filed and had approved by the Director a plan to comply with
33 the provisions of this Section. The compliance plan shall at
34 a minimum include provisions demonstrating that the LHSO will
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1 do all of the following:
2 (1) Design the benefit levels and conditions of
3 coverage for in-plan covered services and out-of-plan
4 covered services as required by this Article.
5 (2) Provide or arrange for the provision of
6 adequate systems to:
7 (A) process and pay claims for all out-of-plan
8 covered services;
9 (B) meet the requirements for a POS contract
10 set forth in this Section and any additional
11 requirements that may be set forth by the Director;
12 and
13 (C) generate accurate data and financial and
14 regulatory reports on a timely basis so that the
15 Department can evaluate the LHSO's experience with
16 the POS contract and monitor compliance with POS
17 contract provisions.
18 (3) Comply initially and on an ongoing basis with
19 the requirements of subsections (b) and (c).
20 (e) A POS contract must comply with the requirements of
21 Section 356w of the Illinois Insurance Code.
22 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
23 Section 25. The Voluntary Health Services Plans Act is
24 amended by changing Section 10 as follows:
25 (215 ILCS 165/10) (from Ch. 32, par. 604)
26 Sec. 10. Application of Insurance Code provisions.
27 Health services plan corporations and all persons interested
28 therein or dealing therewith shall be subject to the
29 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
30 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
31 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
32 paragraphs (7) and (15) of Section 367 of the Illinois
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1 Insurance Code.
2 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
3 90-25, eff. 1-1-98; revised 10-14-97.)
4 Section 95. No acceleration or delay. Where this Act
5 makes changes in a statute that is represented in this Act by
6 text that is not yet or no longer in effect (for example, a
7 Section represented by multiple versions), the use of that
8 text does not accelerate or delay the taking effect of (i)
9 the changes made by this Act or (ii) provisions derived from
10 any other Public Act.
11 Section 99. Effective date. This Act takes effect on
12 January 1, 1999.