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Public Act 91-0406
HB1622 Enrolled LRB9104751JSpc
AN ACT concerning benefits for certain health treatments.
WHEREAS, It is the intent of the General Assembly to
recognize that cancer clinical trials are designed to compare
the effectiveness of the standard medical treatment with a
new therapy that researchers believe will prove more
effective, based on scientific evidence and that such
research provides the foundation for improved patient care
and decreased health care costs; and
WHEREAS, It is the intent of the General Assembly to
recognize that cancer clinical trials involve a rigorously
developed clinical protocol that includes goals, rationale
and background, criteria for patient selection, specific
directions for administering therapy and monitoring patients,
definition of quantitative measures for determining treatment
response, reporting of results, and methods for documenting
and treating adverse reactions; and
WHEREAS, It is the intent of the General Assembly to
recognize that virtually every major breakthrough for current
cancer treatment has been developed through the clinical
trial system; and
WHEREAS, It is the intent of the General Assembly to
acknowledge that cancer clinical trials can be cost neutral
in comparison to the standard therapy; therefore
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Civil Administrative Code of Illinois is
amended by adding Section 56.3 as follows:
(20 ILCS 1405/56.3 new)
Sec. 56.3. Investigational cancer treatments; study.
(a) The Department of Insurance shall conduct an
analysis and study of costs and benefits derived from the
implementation of the coverage requirements for
investigational cancer treatments established under Section
356y of the Illinois Insurance Code. The study shall cover
the years 2000, 2001, and 2002. The study shall include an
analysis of the effect of the coverage requirements on the
cost of insurance and health care, the results of the
treatments to patients, the mortality rate among cancer
patients, any improvements in care of patients, and any
improvements in the quality of life of patients.
(b) The Department shall report the results of its study
to the General Assembly and the Governor on or before March
1, 2003.
Section 10. The Illinois Insurance Code is amended by
adding Section 356y as follows:
(215 ILCS 5/356y new)
Sec. 356y. Coverage for investigational cancer
treatments.
(a) An insurer that issues, delivers, amends, or renews
an individual or group policy of accident and health
insurance in this State more than 120 days after the
effective date of this amendatory Act of the 91st General
Assembly must offer to the applicant or policyholder coverage
for routine patient care of insureds, when medically
appropriate and the insured has a terminal condition related
to cancer that according to the diagnosis of the treating
physician, licensed to practice medicine in all its branches,
is considered life threatening, to participate in an approved
cancer research trial and shall provide coverage for the
patient care provided pursuant to investigational cancer
treatments as provided in subsection (b). Coverage under
this Section may have an annual benefit limit of $10,000.
(b) Coverage shall include routine patient care costs
such as blood tests, x-rays, bone scans, magnetic resonance
images, patient visits, hospital stays, or other similar
costs generally incurred by the insured party in standard
cancer treatment. Routine patient care costs specifically
shall not include the cost of any clinical trial therapies,
regimens, or combinations thereof, any drugs or
pharmaceuticals in connection with an approved clinical
trial, any costs associated with the provision of any goods,
services, or benefits that are generally furnished without
charge in connection with an approved clinical trial program
for treatment of cancer, any additional costs associated with
the provision of any goods, services, or benefits that
previously have been provided to, paid for, or reimbursed, or
any other similar costs. Routine patient care costs shall
specifically not include costs for treatments or services
prescribed for the convenience of the insured, enrollee, or
physician. It is specifically the intent of this Section not
to relieve the sponsor or a clinical trial program of
financial responsibility for accepted costs of the program.
(c) For purposes of this Section, coverage is provided
only for cancer trials that meet each of the following
criteria:
(1) the effectiveness of the treatment has not been
determined relative to established therapies;
(2) the trial is under clinical investigation as
part of an approved cancer research trial in Phase II,
Phase III, or Phase IV of investigation;
(3) the trial is approved by the U.S. Secretary of
Health and Human Services, the Director of the National
Institutes of Health, the Commissioner of the Food and
Drug Administration (through an investigational new drug
exemption under Section 505(l) of the federal Food, Drug,
and Cosmetic Act or an investigational device exemption
under Section 520(g) of that Act), or a qualified
nongovernmental cancer research entity as defined in
guidelines of the National Institutes of Health or a peer
reviewed and approved cancer research program, as defined
by the U.S. Secretary of Health and Human Services,
conducted for the primary purpose of determining whether
or not a cancer treatment is safe or efficacious or has
any other characteristic of a cancer treatment that must
be demonstrated in order for the cancer treatment to be
medically necessary or appropriate;
(4) the trial is being conducted at multiple sites
throughout the State;
(5) the patient's primary care physician, if any,
is involved in the coordination of care; and
(6) the results of the investigational trial will
be submitted for publication in peer-reviewed scientific
studies, research, or literature published in or accepted
for publication by medical journals that meet nationally
recognized requirements for scientific manuscripts and
that submit most of their published articles for review
by experts who are not part of the editorial staff.
These studies may include those conducted by or under the
auspices of the federal government's Agency for Health
Care Policy and Research, National Institutes of Health,
National Cancer Institute, National Academy of Sciences,
Health Care Financing Administration, and any national
board recognized by the National Institutes of Health for
the purpose of evaluating the medical value of health
services.
(d) This Section is repealed on January 1, 2003.
Section 15. The Health Maintenance Organization Act is
amended by changing Section 5-3 as follows:
(215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
Sec. 5-3. Insurance Code provisions.
(a) Health Maintenance Organizations shall be subject to
the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
444, and 444.1, paragraph (c) of subsection (2) of Section
367, and Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
XXV, and XXVI of the Illinois Insurance Code.
(b) For purposes of the Illinois Insurance Code, except
for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
Health Maintenance Organizations in the following categories
are deemed to be "domestic companies":
(1) a corporation authorized under the Dental
Service Plan Act or the Voluntary Health Services Plans
Act;
(2) a corporation organized under the laws of this
State; or
(3) a corporation organized under the laws of
another state, 30% or more of the enrollees of which are
residents of this State, except a corporation subject to
substantially the same requirements in its state of
organization as is a "domestic company" under Article
VIII 1/2 of the Illinois Insurance Code.
(c) In considering the merger, consolidation, or other
acquisition of control of a Health Maintenance Organization
pursuant to Article VIII 1/2 of the Illinois Insurance Code,
(1) the Director shall give primary consideration
to the continuation of benefits to enrollees and the
financial conditions of the acquired Health Maintenance
Organization after the merger, consolidation, or other
acquisition of control takes effect;
(2)(i) the criteria specified in subsection (1)(b)
of Section 131.8 of the Illinois Insurance Code shall not
apply and (ii) the Director, in making his determination
with respect to the merger, consolidation, or other
acquisition of control, need not take into account the
effect on competition of the merger, consolidation, or
other acquisition of control;
(3) the Director shall have the power to require
the following information:
(A) certification by an independent actuary of
the adequacy of the reserves of the Health
Maintenance Organization sought to be acquired;
(B) pro forma financial statements reflecting
the combined balance sheets of the acquiring company
and the Health Maintenance Organization sought to be
acquired as of the end of the preceding year and as
of a date 90 days prior to the acquisition, as well
as pro forma financial statements reflecting
projected combined operation for a period of 2
years;
(C) a pro forma business plan detailing an
acquiring party's plans with respect to the
operation of the Health Maintenance Organization
sought to be acquired for a period of not less than
3 years; and
(D) such other information as the Director
shall require.
(d) The provisions of Article VIII 1/2 of the Illinois
Insurance Code and this Section 5-3 shall apply to the sale
by any health maintenance organization of greater than 10% of
its enrollee population (including without limitation the
health maintenance organization's right, title, and interest
in and to its health care certificates).
(e) In considering any management contract or service
agreement subject to Section 141.1 of the Illinois Insurance
Code, the Director (i) shall, in addition to the criteria
specified in Section 141.2 of the Illinois Insurance Code,
take into account the effect of the management contract or
service agreement on the continuation of benefits to
enrollees and the financial condition of the health
maintenance organization to be managed or serviced, and (ii)
need not take into account the effect of the management
contract or service agreement on competition.
(f) Except for small employer groups as defined in the
Small Employer Rating, Renewability and Portability Health
Insurance Act and except for medicare supplement policies as
defined in Section 363 of the Illinois Insurance Code, a
Health Maintenance Organization may by contract agree with a
group or other enrollment unit to effect refunds or charge
additional premiums under the following terms and conditions:
(i) the amount of, and other terms and conditions
with respect to, the refund or additional premium are set
forth in the group or enrollment unit contract agreed in
advance of the period for which a refund is to be paid or
additional premium is to be charged (which period shall
not be less than one year); and
(ii) the amount of the refund or additional premium
shall not exceed 20% of the Health Maintenance
Organization's profitable or unprofitable experience with
respect to the group or other enrollment unit for the
period (and, for purposes of a refund or additional
premium, the profitable or unprofitable experience shall
be calculated taking into account a pro rata share of the
Health Maintenance Organization's administrative and
marketing expenses, but shall not include any refund to
be made or additional premium to be paid pursuant to this
subsection (f)). The Health Maintenance Organization and
the group or enrollment unit may agree that the
profitable or unprofitable experience may be calculated
taking into account the refund period and the immediately
preceding 2 plan years.
The Health Maintenance Organization shall include a
statement in the evidence of coverage issued to each enrollee
describing the possibility of a refund or additional premium,
and upon request of any group or enrollment unit, provide to
the group or enrollment unit a description of the method used
to calculate (1) the Health Maintenance Organization's
profitable experience with respect to the group or enrollment
unit and the resulting refund to the group or enrollment unit
or (2) the Health Maintenance Organization's unprofitable
experience with respect to the group or enrollment unit and
the resulting additional premium to be paid by the group or
enrollment unit.
In no event shall the Illinois Health Maintenance
Organization Guaranty Association be liable to pay any
contractual obligation of an insolvent organization to pay
any refund authorized under this Section.
(Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-583, eff.
5-29-98; 90-655, eff. 7-30-98; 90-741, eff. 1-1-99; revised
9-8-98.)
Section 20. The Voluntary Health Services Plans Act is
amended by changing Section 10 as follows:
(215 ILCS 165/10) (from Ch. 32, par. 604)
Sec. 10. Application of Insurance Code provisions.
Health services plan corporations and all persons interested
therein or dealing therewith shall be subject to the
provisions of Article XII 1/2 and Sections 3.1, 133, 140,
143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
356x, 356y, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2,
and 412, and paragraphs (7) and (15) of Section 367 of the
Illinois Insurance Code.
(Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff.
1-1-99.)
Section 99. Effective date. This Act takes effect on
January 1, 2000.
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