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92_SB1928
LRB9215996JSpc
1 AN ACT concerning insurance coverage for pregnancy
2 prevention, amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The State Employees Group Insurance Act of
6 1971 is amended by changing Section 6.11 as follows:
7 (5 ILCS 375/6.11)
8 Sec. 6.11. Required health benefits; Illinois Insurance
9 Code requirements. The program of health benefits shall
10 provide the post-mastectomy care benefits required to be
11 covered by a policy of accident and health insurance under
12 Section 356t of the Illinois Insurance Code. The program of
13 health benefits shall provide the coverage required under
14 Sections 356u, 356w, and 356x, 356z.2 of the Illinois
15 Insurance Code. The program of health benefits must comply
16 with Section 155.37 of the Illinois Insurance Code.
17 (Source: P.A. 92-440, eff. 8-17-01.)
18 Section 10. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
20 (55 ILCS 5/5-1069.3)
21 Sec. 5-1069.3. Required health benefits. If a county,
22 including a home rule county, is a self-insurer for purposes
23 of providing health insurance coverage for its employees, the
24 coverage shall include coverage for the post-mastectomy care
25 benefits required to be covered by a policy of accident and
26 health insurance under Section 356t and the coverage required
27 under Sections 356u, 356w, and 356x, and 356z.2 of the
28 Illinois Insurance Code. The requirement that health
29 benefits be covered as provided in this Section is an
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1 exclusive power and function of the State and is a denial and
2 limitation under Article VII, Section 6, subsection (h) of
3 the Illinois Constitution. A home rule county to which this
4 Section applies must comply with every provision of this
5 Section.
6 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
7 Section 15. The Illinois Municipal Code is amended by
8 changing Section 10-4-2.3 as follows:
9 (65 ILCS 5/10-4-2.3)
10 Sec. 10-4-2.3. Required health benefits. If a
11 municipality, including a home rule municipality, is a
12 self-insurer for purposes of providing health insurance
13 coverage for its employees, the coverage shall include
14 coverage for the post-mastectomy care benefits required to be
15 covered by a policy of accident and health insurance under
16 Section 356t and the coverage required under Sections 356u,
17 356w, and 356x, and 356z.2 of the Illinois Insurance Code.
18 The requirement that health benefits be covered as provided
19 in this is an exclusive power and function of the State and
20 is a denial and limitation under Article VII, Section 6,
21 subsection (h) of the Illinois Constitution. A home rule
22 municipality to which this Section applies must comply with
23 every provision of this Section.
24 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
25 Section 20. The School Code is amended by changing
26 Section 10-22.3f as follows:
27 (105 ILCS 5/10-22.3f)
28 Sec. 10-22.3f. Required health benefits. Insurance
29 protection and benefits for employees shall provide the
30 post-mastectomy care benefits required to be covered by a
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1 policy of accident and health insurance under Section 356t
2 and the coverage required under Sections 356u, 356w, and
3 356x, and 356z.2 of the Illinois Insurance Code.
4 (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)
5 Section 25. The Illinois Insurance Code is amended by
6 adding Section 356z.2 as follows:
7 (215 ILCS 5/356z.2 new)
8 Sec. 356z.2. Clinical cancer trials; routine patient
9 care costs.
10 (a) For the purposes of this Section, the following
11 terms have the following meanings:
12 (1) "Clinical or principal investigator" means the
13 person managing the clinical trial.
14 (2) "Life threatening disease or condition" means a
15 disease or condition, which includes, but is not limited
16 to, breast cancer, prostate cancer, and leukemia, in
17 which either or both of the following is applicable:
18 (A) The likelihood of death is high unless the
19 course of the disease or condition is interrupted.
20 (B) The outcome is potentially fatal and the
21 purpose of clinical intervention is survival.
22 (3) "Routine patient care costs" means the costs
23 associated with the provision of items and services that
24 would otherwise be covered under the policy if those
25 items and services were not provided in connection with
26 an approved clinical trial program. For purposes of this
27 Section, "routine patient care costs" does not include
28 the costs associated with the provision of any of the
29 following:
30 (A) The cost of an investigational drug or
31 device.
32 (B) The cost of services other than health
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1 care services that an insured may require as a
2 result of the treatment being provided for purposes
3 of the clinical trial.
4 (C) The costs associated with managing the
5 research associated with the clinical trial.
6 (D) The costs that would not be covered under
7 the insured's coverage with respect to a medical
8 procedure not involving a clinical trial.
9 (b) A group or individual policy of accident and health
10 insurance that is amended, delivered, issued, or renewed in
11 this State on and after the effective date of this amendatory
12 Act of the 92nd General Assembly must provide coverage for
13 routine patient care costs for an insured for treatment in a
14 Phase II through Phase III clinical trial that meets the
15 requirements of this Section, if all of the following
16 conditions are met:
17 (1) the treatment is being provided for a
18 life-threatening disease or condition;
19 (2) the insured's physician recommends
20 participation in the clinical trial; and
21 (3) the insured's physician certifies that the
22 clinical trial is likely to be more beneficial for the
23 insured than any available standard therapy.
24 (c) The treatment shall be provided in a clinical trial
25 approved by one of the following:
26 (1) One of the National Institutes of Health.
27 (2) The federal Food and Drug Administration, in
28 the form of an investigational new drug application.
29 (3) The Department of Defense.
30 (d) In the case of routine patient care costs provided
31 by a participating provider, the payment rate shall be at the
32 agreed upon rate. In the case of a nonparticipating provider,
33 the payment rate shall be at the rate the insurer would pay
34 to a participating provider for comparable services. Nothing
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1 in this Section shall be construed to prohibit an insurer
2 from restricting coverage for clinical trials to
3 participating hospitals and physicians in Illinois unless the
4 protocol for the clinical trial is not provided for at an
5 Illinois hospital or by an Illinois physician.
6 (e) The clinical or principal investigator seeking
7 coverage on behalf of an insured for treatment in a clinical
8 trial approved pursuant to subsection (c) shall post
9 electronically on the National Cancer Institute's national
10 physician data query data base a current list of the clinical
11 trials for which he or she is seeking coverage and that meet
12 the requirements of subsection (b).
13 This information shall also be provided to the insured's
14 insurer.
15 The list shall include, for each clinical trial, all of
16 the following:
17 (1) The name of the trial.
18 (2) The phase of the trial.
19 (3) The disease being treated by the trial.
20 (4) The method by which further information about
21 the trial may be obtained.
22 (f) On or before June 1 of each year, an insurer shall
23 submit a report to the Director, in a form required by the
24 Director, that describes the clinical trials that the insurer
25 covered with respect to an insured. The Director shall
26 compile an annual summary report. A copy of the annual
27 summary report shall be provided to the Governor and to the
28 General Assembly.
29 Section 30. The Health Maintenance Organization Act is
30 amended by changing Section 5-3 as follows:
31 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
32 Sec. 5-3. Insurance Code provisions.
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1 (a) Health Maintenance Organizations shall be subject to
2 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
3 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
4 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
5 356y, 356z.2, 367i, 368a, 401, 401.1, 402, 403, 403A, 408,
6 408.2, 409, 412, 444, and 444.1, paragraph (c) of subsection
7 (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
8 XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
9 (b) For purposes of the Illinois Insurance Code, except
10 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
11 Health Maintenance Organizations in the following categories
12 are deemed to be "domestic companies":
13 (1) a corporation authorized under the Dental
14 Service Plan Act or the Voluntary Health Services Plans
15 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. 90-25, eff. 1-1-98; 90-177, eff. 7-23-97;
18 90-372, eff. 7-1-98; 90-583, eff. 5-29-98; 90-655, eff.
19 7-30-98; 90-741, eff. 1-1-99; 91-357, eff. 7-29-99; 91-406,
20 eff. 1-1-00; 91-549, eff. 8-14-99; 91-605, eff. 12-14-99;
21 91-788, eff. 6-9-00.)
22 Section 35. The Voluntary Health Services Plans Act is
23 amended by changing Section 10 as follows:
24 (215 ILCS 165/10) (from Ch. 32, par. 604)
25 Sec. 10. Application of Insurance Code provisions.
26 Health services plan corporations and all persons interested
27 therein or dealing therewith shall be subject to the
28 provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
29 140, 143, 143c, 149, 155.37, 354, 355.2, 356r, 356t, 356u,
30 356v, 356w, 356x, 356y, 356z.1, 356z.2, 367.2, 368a, 401,
31 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs
32 (7) and (15) of Section 367 of the Illinois Insurance Code.
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1 (Source: P.A. 91-406, eff. 1-1-00; 91-549, eff. 8-14-99;
2 91-605, eff. 12-14-99; 91-788, eff. 6-9-00; 92-130, eff.
3 7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)
4 Section 95. The State Mandates Act is amended by adding
5 Section 8.26 as follows:
6 (30 ILCS 805/8.26 new)
7 Sec. 8.26. Exempt mandate. Notwithstanding Sections 6
8 and 8 of this Act, no reimbursement by the State is required
9 for the implementation of any mandate created by this
10 amendatory Act of the 92nd General Assembly.