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90_HB3339eng
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
HB3339 Engrossed 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, reporting of results, and methods for documenting
16 and treating adverse reactions; and
17 WHEREAS, It is the intent of the General Assembly to
18 recognize that virtually every major breakthrough for current
19 cancer treatment has been developed through the clinical
20 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 10. The Illinois Insurance Code is amended by
27 adding Section 356w as follows:
28 (215 ILCS 5/356w new)
29 Sec. 356w. Coverage for investigational cancer
HB3339 Engrossed -2- LRB9010497JSpk
1 treatments.
2 (a) An individual or group policy of accident and health
3 insurance issued, delivered, amended, or renewed in this
4 State after the effective date of this amendatory Act of 1998
5 must provide coverage for patient care of insureds, when
6 medically appropriate, to participate in an approved research
7 trial and shall provide coverage for the patient care
8 provided pursuant to investigational cancer treatments as
9 provided in subsection (b).
10 (b) Coverage must be included for an item or service
11 that would otherwise be covered, subject to the limitations
12 and cost sharing requirements applicable to the item or
13 service, when that item or service is provided to an insured
14 in the course of an investigational cancer treatment if:
15 (1) the treatment is a qualifying cancer
16 investigational treatment; and
17 (2) the cancer treatment is administered as part of
18 the medical management of a life-threatening disease,
19 disorder, or health condition.
20 Coverage must be included for an item or service when
21 that item or service is required to provide patient care
22 pursuant to the design of a research trial, except those
23 items or services normally paid for by other funding sources,
24 such as the costs of certain investigational agents, the
25 costs of any nonhealth services that might be required for a
26 person to receive cancer treatment, and the costs of managing
27 the research; items or services subject to this exception may
28 be covered in addition to patient care at the discretion of
29 the health plan.
30 (c) For purposes of this Section, (A) "qualifying
31 investigational cancer treatment" means a treatment (i) the
32 effectiveness of which has not been determined and (ii) that
33 is under clinical investigation as part of an approved cancer
34 research trial in Phase II, Phase III, or Phase IV of
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1 investigation and (B) "approved cancer research trial" means
2 (i) a cancer research trial approved by the U.S. Secretary of
3 Health and Human Services, the Director of the National
4 Institutes of Health, the Commissioner of the Food and Drug
5 Administration (through an investigational new drug exemption
6 under Section 505(1) of the federal Food, Drug and Cosmetic
7 Act or an investigational device exemption under Section
8 520(g) of that Act), the Secretary of Veterans Affairs, the
9 Secretary of Defense, or a qualified nongovernmental cancer
10 research entity as defined in guidelines of the National
11 Institutes of Health or (ii) a peer-reviewed and approved
12 cancer research program, as defined by the U.S. Secretary of
13 Health and Human Services, conducted for the primary purpose
14 of determining whether or not a cancer treatment is safe or
15 efficacious or has any other characteristic of a cancer
16 treatment that must be demonstrated in order for the cancer
17 treatment to be medically necessary or appropriate.
18 (d) This Section is repealed on January 1, 2002.
19 Section 15. The Health Maintenance Organization Act is
20 amended by changing Section 5-3 as follows:
21 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
22 (Text of Section before amendment by P.A. 90-372)
23 Sec. 5-3. Insurance Code provisions.
24 (a) Health Maintenance Organizations shall be subject to
25 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
26 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
27 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
28 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
29 paragraph (c) of subsection (2) of Section 367, and Articles
30 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
31 Illinois Insurance Code.
32 (b) For purposes of the Illinois Insurance Code, except
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1 for Articles XIII and XIII 1/2, Health Maintenance
2 Organizations in the following categories are deemed to be
3 "domestic companies":
4 (1) a corporation authorized under the Medical
5 Service Plan Act, the Dental Service Plan Act, the
6 Pharmaceutical Service Plan Act, or the Voluntary Health
7 Services Plans Plan Act, or the Nonprofit Health Care
8 Service Plan Act;
9 (2) a corporation organized under the laws of this
10 State; or
11 (3) a corporation organized under the laws of
12 another state, 30% or more of the enrollees of which are
13 residents of this State, except a corporation subject to
14 substantially the same requirements in its state of
15 organization as is a "domestic company" under Article
16 VIII 1/2 of the Illinois Insurance Code.
17 (c) In considering the merger, consolidation, or other
18 acquisition of control of a Health Maintenance Organization
19 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20 (1) the Director shall give primary consideration
21 to the continuation of benefits to enrollees and the
22 financial conditions of the acquired Health Maintenance
23 Organization after the merger, consolidation, or other
24 acquisition of control takes effect;
25 (2)(i) the criteria specified in subsection (1)(b)
26 of Section 131.8 of the Illinois Insurance Code shall not
27 apply and (ii) the Director, in making his determination
28 with respect to the merger, consolidation, or other
29 acquisition of control, need not take into account the
30 effect on competition of the merger, consolidation, or
31 other acquisition of control;
32 (3) the Director shall have the power to require
33 the following information:
34 (A) certification by an independent actuary of
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1 the adequacy of the reserves of the Health
2 Maintenance Organization sought to be acquired;
3 (B) pro forma financial statements reflecting
4 the combined balance sheets of the acquiring company
5 and the Health Maintenance Organization sought to be
6 acquired as of the end of the preceding year and as
7 of a date 90 days prior to the acquisition, as well
8 as pro forma financial statements reflecting
9 projected combined operation for a period of 2
10 years;
11 (C) a pro forma business plan detailing an
12 acquiring party's plans with respect to the
13 operation of the Health Maintenance Organization
14 sought to be acquired for a period of not less than
15 3 years; and
16 (D) such other information as the Director
17 shall require.
18 (d) The provisions of Article VIII 1/2 of the Illinois
19 Insurance Code and this Section 5-3 shall apply to the sale
20 by any health maintenance organization of greater than 10% of
21 its enrollee population (including without limitation the
22 health maintenance organization's right, title, and interest
23 in and to its health care certificates).
24 (e) In considering any management contract or service
25 agreement subject to Section 141.1 of the Illinois Insurance
26 Code, the Director (i) shall, in addition to the criteria
27 specified in Section 141.2 of the Illinois Insurance Code,
28 take into account the effect of the management contract or
29 service agreement on the continuation of benefits to
30 enrollees and the financial condition of the health
31 maintenance organization to be managed or serviced, and (ii)
32 need not take into account the effect of the management
33 contract or service agreement on competition.
34 (f) Except for small employer groups as defined in the
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1 Small Employer Rating, Renewability and Portability Health
2 Insurance Act and except for medicare supplement policies as
3 defined in Section 363 of the Illinois Insurance Code, a
4 Health Maintenance Organization may by contract agree with a
5 group or other enrollment unit to effect refunds or charge
6 additional premiums under the following terms and conditions:
7 (i) the amount of, and other terms and conditions
8 with respect to, the refund or additional premium are set
9 forth in the group or enrollment unit contract agreed in
10 advance of the period for which a refund is to be paid or
11 additional premium is to be charged (which period shall
12 not be less than one year); and
13 (ii) the amount of the refund or additional premium
14 shall not exceed 20% of the Health Maintenance
15 Organization's profitable or unprofitable experience with
16 respect to the group or other enrollment unit for the
17 period (and, for purposes of a refund or additional
18 premium, the profitable or unprofitable experience shall
19 be calculated taking into account a pro rata share of the
20 Health Maintenance Organization's administrative and
21 marketing expenses, but shall not include any refund to
22 be made or additional premium to be paid pursuant to this
23 subsection (f)). The Health Maintenance Organization and
24 the group or enrollment unit may agree that the
25 profitable or unprofitable experience may be calculated
26 taking into account the refund period and the immediately
27 preceding 2 plan years.
28 The Health Maintenance Organization shall include a
29 statement in the evidence of coverage issued to each enrollee
30 describing the possibility of a refund or additional premium,
31 and upon request of any group or enrollment unit, provide to
32 the group or enrollment unit a description of the method used
33 to calculate (1) the Health Maintenance Organization's
34 profitable experience with respect to the group or enrollment
HB3339 Engrossed -7- LRB9010497JSpk
1 unit and the resulting refund to the group or enrollment unit
2 or (2) the Health Maintenance Organization's unprofitable
3 experience with respect to the group or enrollment unit and
4 the resulting additional premium to be paid by the group or
5 enrollment unit.
6 In no event shall the Illinois Health Maintenance
7 Organization Guaranty Association be liable to pay any
8 contractual obligation of an insolvent organization to pay
9 any refund authorized under this Section.
10 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
11 90-177, eff. 7-23-97; revised 11-21-97.)
12 (Text of Section after amendment by P.A. 90-372)
13 Sec. 5-3. Insurance Code provisions.
14 (a) Health Maintenance Organizations shall be subject to
15 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
16 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
17 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356t,
18 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412,
19 paragraph (c) of subsection (2) of Section 367, and Articles
20 VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, and XXVI of the
21 Illinois Insurance Code.
22 (b) For purposes of the Illinois Insurance Code, except
23 for Articles XIII and XIII 1/2, Health Maintenance
24 Organizations in the following categories are deemed to be
25 "domestic companies":
26 (1) a corporation authorized under the Medical
27 Service Plan Act, the Dental Service Plan Act or, the
28 Voluntary Health Services Plans Plan Act, or the
29 Nonprofit Health Care Service Plan Act;
30 (2) a corporation organized under the laws of this
31 State; or
32 (3) a corporation organized under the laws of
33 another state, 30% or more of the enrollees of which are
34 residents of this State, except a corporation subject to
HB3339 Engrossed -8- LRB9010497JSpk
1 substantially the same requirements in its state of
2 organization as is a "domestic company" under Article
3 VIII 1/2 of the Illinois Insurance Code.
4 (c) In considering the merger, consolidation, or other
5 acquisition of control of a Health Maintenance Organization
6 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
7 (1) the Director shall give primary consideration
8 to the continuation of benefits to enrollees and the
9 financial conditions of the acquired Health Maintenance
10 Organization after the merger, consolidation, or other
11 acquisition of control takes effect;
12 (2)(i) the criteria specified in subsection (1)(b)
13 of Section 131.8 of the Illinois Insurance Code shall not
14 apply and (ii) the Director, in making his determination
15 with respect to the merger, consolidation, or other
16 acquisition of control, need not take into account the
17 effect on competition of the merger, consolidation, or
18 other acquisition of control;
19 (3) the Director shall have the power to require
20 the following information:
21 (A) certification by an independent actuary of
22 the adequacy of the reserves of the Health
23 Maintenance Organization sought to be acquired;
24 (B) pro forma financial statements reflecting
25 the combined balance sheets of the acquiring company
26 and the Health Maintenance Organization sought to be
27 acquired as of the end of the preceding year and as
28 of a date 90 days prior to the acquisition, as well
29 as pro forma financial statements reflecting
30 projected combined operation for a period of 2
31 years;
32 (C) a pro forma business plan detailing an
33 acquiring party's plans with respect to the
34 operation of the Health Maintenance Organization
HB3339 Engrossed -9- LRB9010497JSpk
1 sought to be acquired for a period of not less than
2 3 years; and
3 (D) such other information as the Director
4 shall require.
5 (d) The provisions of Article VIII 1/2 of the Illinois
6 Insurance Code and this Section 5-3 shall apply to the sale
7 by any health maintenance organization of greater than 10% of
8 its enrollee population (including without limitation the
9 health maintenance organization's right, title, and interest
10 in and to its health care certificates).
11 (e) In considering any management contract or service
12 agreement subject to Section 141.1 of the Illinois Insurance
13 Code, the Director (i) shall, in addition to the criteria
14 specified in Section 141.2 of the Illinois Insurance Code,
15 take into account the effect of the management contract or
16 service agreement on the continuation of benefits to
17 enrollees and the financial condition of the health
18 maintenance organization to be managed or serviced, and (ii)
19 need not take into account the effect of the management
20 contract or service agreement on competition.
21 (f) Except for small employer groups as defined in the
22 Small Employer Rating, Renewability and Portability Health
23 Insurance Act and except for medicare supplement policies as
24 defined in Section 363 of the Illinois Insurance Code, a
25 Health Maintenance Organization may by contract agree with a
26 group or other enrollment unit to effect refunds or charge
27 additional premiums under the following terms and conditions:
28 (i) the amount of, and other terms and conditions
29 with respect to, the refund or additional premium are set
30 forth in the group or enrollment unit contract agreed in
31 advance of the period for which a refund is to be paid or
32 additional premium is to be charged (which period shall
33 not be less than one year); and
34 (ii) the amount of the refund or additional premium
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1 shall not exceed 20% of the Health Maintenance
2 Organization's profitable or unprofitable experience with
3 respect to the group or other enrollment unit for the
4 period (and, for purposes of a refund or additional
5 premium, the profitable or unprofitable experience shall
6 be calculated taking into account a pro rata share of the
7 Health Maintenance Organization's administrative and
8 marketing expenses, but shall not include any refund to
9 be made or additional premium to be paid pursuant to this
10 subsection (f)). The Health Maintenance Organization and
11 the group or enrollment unit may agree that the
12 profitable or unprofitable experience may be calculated
13 taking into account the refund period and the immediately
14 preceding 2 plan years.
15 The Health Maintenance Organization shall include a
16 statement in the evidence of coverage issued to each enrollee
17 describing the possibility of a refund or additional premium,
18 and upon request of any group or enrollment unit, provide to
19 the group or enrollment unit a description of the method used
20 to calculate (1) the Health Maintenance Organization's
21 profitable experience with respect to the group or enrollment
22 unit and the resulting refund to the group or enrollment unit
23 or (2) the Health Maintenance Organization's unprofitable
24 experience with respect to the group or enrollment unit and
25 the resulting additional premium to be paid by the group or
26 enrollment unit.
27 In no event shall the Illinois Health Maintenance
28 Organization Guaranty Association be liable to pay any
29 contractual obligation of an insolvent organization to pay
30 any refund authorized under this Section.
31 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
32 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; revised 11-21-97.)
33 Section 20. The Limited Health Service Organization Act
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1 is amended by changing Section 3009 as follows:
2 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
3 Sec. 3009. Point-of-service limited health service
4 contracts.
5 (a) An LHSO that offers a POS contract:
6 (1) shall include as in-plan covered services all
7 services required by law to be provided by an LHSO;
8 (2) shall provide incentives, which shall include
9 financial incentives, for enrollees to use in-plan
10 covered services;
11 (3) shall not offer services out-of-plan without
12 providing those services on an in-plan basis;
13 (4) may limit or exclude specific types of services
14 from coverage when obtained out-of-plan;
15 (5) may include annual out-of-pocket limits and
16 lifetime maximum benefits allowances for out-of-plan
17 services that are separate from any limits or allowances
18 applied to in-plan services;
19 (6) shall include an annual maximum benefit
20 allowance not to exceed $2,500 per year that is separate
21 from any limits or allowances applied to in-plan
22 services;
23 (7) may limit the groups to which a POS product is
24 offered, however, if a POS product is offered to a group,
25 then it must be offered to all eligible members of that
26 group, when an LHSO provider is available;
27 (8) shall not consider emergency services,
28 authorized referral services, or non-routine services
29 obtained out of the service area to be POS services; and
30 (9) may treat as out-of-plan services those
31 services that an enrollee obtains from a participating
32 provider, but for which the proper authorization was not
33 given by the LHSO.
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1 (b) An LHSO offering a POS contract shall be subject to
2 the following limitations:
3 (1) The LHSO shall not expend in any calendar
4 quarter more than 20% of its total limited health
5 services expenditures for all its members for out-of-plan
6 covered services.
7 (2) If the amount specified in paragraph (1) is
8 exceeded by 2% in a quarter, the LHSO shall effect
9 compliance with paragraph (1) by the end of the following
10 quarter.
11 (3) If compliance with the amount specified in
12 paragraph (1) is not demonstrated in the LHSO's next
13 quarterly report, the LHSO may not offer the POS contract
14 to new groups or include the POS option in the renewal of
15 an existing group until compliance with the amount
16 specified in paragraph (1) is demonstrated or otherwise
17 allowed by the Director.
18 (4) Any LHSO failing, without just cause, to comply
19 with the provisions of this subsection shall be required,
20 after notice and hearing, to pay a penalty of $250 for
21 each day out of compliance, to be recovered by the
22 Director of Insurance. Any penalty recovered shall be
23 paid into the General Revenue Fund. The Director may
24 reduce the penalty if the LHSO demonstrates to the
25 Director that the imposition of the penalty would
26 constitute a financial hardship to the LHSO.
27 (c) Any LHSO that offers a POS product shall:
28 (1) File a quarterly financial statement detailing
29 compliance with the requirements of subsection (b).
30 (2) Track out-of-plan POS utilization separately
31 from in-plan or non-POS out-of-plan emergency care,
32 referral care, and urgent care out of the service area
33 utilization.
34 (3) Record out-of-plan utilization in a manner that
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1 will permit such utilization and cost reporting as the
2 Director may, by regulation, require.
3 (4) Demonstrate to the Director's satisfaction that
4 the LHSO has the fiscal, administrative, and marketing
5 capacity to control its POS enrollment, utilization, and
6 costs so as not to jeopardize the financial security of
7 the LHSO.
8 (5) Maintain the deposit required by subsection (b)
9 of Section 2006 in addition to any other deposit required
10 under this Act.
11 (d) An LHSO shall not issue a POS contract until it has
12 filed and had approved by the Director a plan to comply with
13 the provisions of this Section. The compliance plan shall at
14 a minimum include provisions demonstrating that the LHSO will
15 do all of the following:
16 (1) Design the benefit levels and conditions of
17 coverage for in-plan covered services and out-of-plan
18 covered services as required by this Article.
19 (2) Provide or arrange for the provision of
20 adequate systems to:
21 (A) process and pay claims for all out-of-plan
22 covered services;
23 (B) meet the requirements for a POS contract
24 set forth in this Section and any additional
25 requirements that may be set forth by the Director;
26 and
27 (C) generate accurate data and financial and
28 regulatory reports on a timely basis so that the
29 Department can evaluate the LHSO's experience with
30 the POS contract and monitor compliance with POS
31 contract provisions.
32 (3) Comply initially and on an ongoing basis with
33 the requirements of subsections (b) and (c).
34 (e) A POS contract must comply with the requirements of
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1 Section 356w of the Illinois Insurance Code.
2 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
3 Section 25. The Voluntary Health Services Plans Act is
4 amended by changing Section 10 as follows:
5 (215 ILCS 165/10) (from Ch. 32, par. 604)
6 Sec. 10. Application of Insurance Code provisions.
7 Health services plan corporations and all persons interested
8 therein or dealing therewith shall be subject to the
9 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
10 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
11 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
12 paragraphs (7) and (15) of Section 367 of the Illinois
13 Insurance Code.
14 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
15 90-25, eff. 1-1-98; revised 10-14-97.)
16 Section 95. No acceleration or delay. Where this Act
17 makes changes in a statute that is represented in this Act by
18 text that is not yet or no longer in effect (for example, a
19 Section represented by multiple versions), the use of that
20 text does not accelerate or delay the taking effect of (i)
21 the changes made by this Act or (ii) provisions derived from
22 any other Public Act.
23 Section 99. Effective date. This Act takes effect on
24 January 1, 1999.