Public Act 097-0091
 
HB1191 EnrolledLRB097 06572 RPM 46657 b



    AN ACT concerning insurance.

 
    Be it enacted by the People of the State of Illinois, 
represented in the General Assembly: 



 
    Section 5. The Illinois Insurance Code is amended  by 
changing Sections 356z.16 and 364.01 as follows:
 
    (215 ILCS 5/356z.16)
    Sec. 356z.16. Applicability of mandated benefits to 
supplemental policies. Unless specified otherwise, the 
following Sections of the Illinois Insurance Code do not apply 
to short-term travel, disability income, long-term care, 
accident only, or limited or specified disease policies: 356b, 
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, 
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 
356z.8, 356z.12, 364.01, 367.2-5, and 367e.

(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; 
96-1034, eff. 1-1-11.)
 
    (215 ILCS 5/364.01)
    Sec. 364.01. Qualified clinical cancer trials.
    (a) No individual or group policy of accident and health 
insurance issued or renewed in this State may be cancelled or 
non-renewed for any individual based on that individual's 
participation in a qualified clinical cancer trial.
    (b) Qualified clinical cancer trials must meet 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:
            (A) approved by the Food and Drug Administration; 
        or
            (B) approved and funded by the National Institutes 
        of Health, the   Centers for Disease Control and 
        Prevention, the Agency for Healthcare Research and 
        Quality, the United States Department of Defense, the 
        United States Department of Veterans Affairs, or the 
        United States Department of Energy in the form of an 
        investigational new drug application, or a cooperative 
        group or center of any entity described in this 
        subdivision (B); and

        (4) the patient's primary care physician, if any, is 
    involved in the coordination of care.

    (c) No group policy of accident and health insurance shall 
exclude coverage for any routine patient care administered to 
an insured who is a qualified individual participating in a 
qualified clinical cancer trial, if the policy covers that same 
routine patient care of insureds not enrolled in a qualified 
clinical cancer trial.
    (d) The coverage that may not be excluded under subsection 
(c) of this Section is subject to all terms, conditions, 
restrictions, exclusions, and limitations that apply to the 
same routine patient care received by an insured not enrolled 
in a qualified clinical cancer trial, including the application 
of any authorization requirement, utilization review, or 
medical management practices. The insured or enrollee shall 
incur no greater out-of-pocket liability than had the insured 
or enrollee not enrolled in a qualified clinical cancer trial.
    (e) If the group policy of accident and health insurance 
uses a preferred provider program and a preferred provider 
provides routine patient care in connection with a qualified 
clinical cancer trial, then the insurer may require the insured 
to use the preferred provider if the preferred provider agrees 
to provide to the insured that routine patient care.
    (f) A qualified clinical cancer trial may not pay or refuse 
to pay for routine patient care of an individual participating 
in the trial, based in whole or in part on the person's having 
or not having coverage for routine patient care under a group 
policy of accident and health insurance.
    (g) Nothing in this Section shall be construed to limit an 
insurer's coverage with respect to clinical trials.
    (h) Nothing in this Section shall require coverage for 
out-of-network services where the underlying health benefit 
plan does not provide coverage for out-of-network services.
    (i) As used in this Section, "routine patient care" means 
all health care services provided in the qualified clinical 
cancer trial that are otherwise generally covered under the 
policy if those items or services were not provided in 
connection with a qualified clinical cancer trial consistent 
with the standard of care for the treatment of cancer, 
including the type and frequency of any diagnostic modality, 
that a provider typically provides to a cancer patient who is 
not enrolled in a qualified clinical cancer trial. "Routine 
patient care" does not include, and  a group policy of accident 
and health insurance may exclude, coverage for:
        (1) a health care service, item, or drug that is the 
    subject of the cancer clinical trial;
        (2) a health care service, item, or drug provided 
    solely to satisfy data collection and analysis needs for 
    the qualified clinical cancer trial that is not used in the 
    direct clinical management of the patient;
        (3) an investigational drug or device that has not been 
    approved for market by the United States Food and Drug 
    Administration;
        (4) transportation, lodging, food, or other expenses 
    for the patient or a family member or companion of the 
    patient that are associated with the travel to or from a 
    facility providing the qualified clinical cancer trial, 
    unless the policy covers these expenses for a cancer 
    patient who is not enrolled in a qualified clinical cancer 
    trial;
        (5) a health care service, item, or drug customarily 
    provided by the qualified clinical cancer trial sponsors 
    free of charge for any patient;
        (6) a health care service or item, which except for the 
    fact that it is being provided in a qualified clinical 
    cancer trial, is otherwise specifically excluded from 
    coverage under the insured's policy, including:
            (A) costs of extra treatments, services, 
        procedures, tests, or drugs that would not be performed 
        or administered except for the fact that the insured is 
        participating in the cancer clinical trial; and
            (B) costs of nonhealth care services that the 
        patient is required to receive as a result of 
        participation in the approved cancer clinical trial;
        (7) costs for services, items, or drugs that are 
    eligible for reimbursement from a source other than a 
    patient's contract or policy providing for third-party 
    payment or prepayment of health or medical expenses, 
    including the sponsor of the approved cancer clinical 
    trial; or
        (8) costs associated with approved cancer clinical 
    trials designed exclusively to test toxicity or disease 
    pathophysiology, unless the policy covers these expenses 
    for a cancer patient who is not enrolled in a qualified 
    clinical cancer trial; or
        (9) a health care service or item that is eligible for 
    reimbursement by a source other than the insured's policy, 
    including the sponsor of the qualified clinical cancer 
    trial.
    The definitions of the terms "health care services", 
"Non-Preferred Provider", "Preferred Provider", and "Preferred 
Provider Program", stated in 50 IL Adm. Code Part 2051 
Preferred Provider Programs apply to these terms in this 
Section.
    (j) The external review procedures established under the 
Health Carrier External Review Act shall apply to the 
provisions under this Section.
(Source: P.A. 93-1000, eff. 1-1-05.)
 

    Section 99. Effective date. This Act takes effect January 
1, 2012.