HB5230 101ST GENERAL ASSEMBLY

LRB101 18346 BMS 67793 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB5230

Introduced , by Rep. Michael D. Unes

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.43 new

Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2021 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with intensity modulated radiation therapy for the same indication if specified conditions are satisfied. Provides standards concerning the aggregate amount chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy. Provides that proton therapy coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract. Defines terms. Effective January 1, 2021.

A BILL FOR

AN ACT concerning regulation.

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 adding Section 356z.43 as follows:

(215 ILCS 5/356z.43 new)

Sec. 356z.43. Proton therapy access.

(a) As used in this Section:

"Aggregate amount" means the total amount paid under an individual or group policy of accident and health insurance for the applicable radiation treatment delivery current procedural terminology codes to deliver a biological effective dose.

"Biological effective dose" means the total prescribed radiation dose delivered in a course of radiation therapy treatments to induce tumor cell death.

"Current procedural terminology code" means the unique numerical designations established by the American Medical Association for various medical, surgical, and diagnostic services used in billing health care services.

"Eligible patient" means a cancer patient who is approved for a standard radiation therapy protocol delivered with IMRT and prescribed a hypofractionated proton therapy protocol for the treatment of the same cancer.

"Hypofractionated proton therapy protocol" means a cancer treatment protocol that involves the delivery of fewer, larger radiation therapy treatment doses than a standard radiation therapy protocol to deliver a biological effective dose.

"Intensity modulated radiation therapy" or "IMRT" means a type of conformal radiation therapy that delivers x-ray radiation beams of different intensities from many angles for the treatment of tumors.

"Proton therapy" means the advanced form of radiation therapy that utilizes protons as the radiation delivery method for the treatment of tumors.

"Radiation therapy" means the delivery of a biological effective dose with proton therapy, IMRT, brachytherapy, stereotactic body radiation therapy, three-dimensional conformal radiation therapy, or other forms of therapy using radiation.

"Registry" means an organized system that uses observational study methods to collect uniform clinical data to evaluate specified outcomes for a population defined by a particular disease and is compliant with the principles established by the Registries for Evaluating Patient Outcomes: A User's Guide - Third Edition published by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.

"Standard radiation therapy protocol" means a cancer treatment protocol that involves the delivery of radiation therapy treatment doses over an extended period of time to deliver a biological effective dose.

"Treatment dose" means the amount of radiation delivered in a single treatment or fraction of radiation therapy.

(b) An individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2021 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with IMRT for the same indication if the following conditions are satisfied:

(1) coverage is provided to an eligible patient who is being treated as part of a clinical trial or registry;

(2) the eligible patient is diagnosed with a cancer type or indication that can be treated with a hypofractionated proton therapy protocol; and

(3) the radiation oncologist prescribing the hypofractionated proton therapy protocol is board certified or board eligible in the specialty of radiation oncology.

(c) If coverage of a hypofractionated proton therapy protocol is required pursuant to subsection (b), then:

(1) the aggregate amount must be equal to the average cost actually paid by an individual or group policy of accident and health insurance for a standard radiation therapy protocol delivered with IMRT required to deliver the prescribed biological effective dose for the particular indication. For the purposes of this paragraph (1), aggregate amounts must be established by reference to the amount paid for a course of IMRT treatment under a standard radiation therapy protocol delivered with IMRT for the indication under the applicable policy; and

(2) coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract.

(d) Notwithstanding any other provision of this Section to the contrary, the aggregate amount:

(1) reimbursed for the hypofractionated proton therapy protocol must not exceed the average aggregate amount paid by an individual or group policy of accident and health insurance for a course of IMRT treatment under a standard radiation therapy protocol delivered with IMRT to deliver the prescribed biological effective dose for the same indication;

(2) chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy by an in-network provider must not exceed the aggregate amount that would otherwise be chargeable to or payable by the eligible patient for a course of IMRT treatment under a standard radiation therapy protocol delivered with IMRT that is covered by the applicable policy for the delivery of the same biological effective dose by an in-network provider; and

(3) chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy by an out-of-network provider must not exceed the aggregate amount that would otherwise be chargeable to or payable by the eligible patient for a course of treatment under a standard radiation therapy protocol delivered with IMRT that is covered by the applicable policy for the delivery of the same biological effective dose by an out-of-network provider. However, the patient is not responsible for amounts greater than the allowable maximum charge.

Section 99. Effective date. This Act takes effect January 1, 2021.