HB5576 99TH GENERAL ASSEMBLY

LRB099 20488 EGJ 45009 b

99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB5576

Introduced , by Rep. Elaine Nekritz

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.4

Amends the Illinois Insurance Code. Makes changes to a Section concerning coverage for contraceptives. Provides that that an individual or group health policy shall provide coverage for all contraceptive drugs, devices, and other products approved by the United States Food and Drug Administration, including over-the-counter contraceptive drugs, devices, and products; voluntarily sterilization procedures; contraceptive services, patient education, and counseling on contraception; and follow-up services related to their use. Provides that if the United States Food and Drug Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing; if an individual's attending provider recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing and the plan or issuer must defer to the determination of the attending provider; if a drug, device or product is not covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual, provider or person acting as a patient's authorized representative to ensure coverage without cost sharing; and that coverage must provide for the dispensing of 12 months' worth of contraception at one time. Defines "contraceptive services", "medical necessity", and "therapeutic equivalent version". Removes language prohibiting the provisions from being construed to require an insurance company cover services related to permanent sterilization requiring a surgical procedure.

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 changing Section 356z.4 as follows:

(215 ILCS 5/356z.4)

Sec. 356z.4. Coverage for contraceptives.

(a) The General Assembly hereby finds and declares all of the following:

(1) Illinois has a long history of expanding timely access to birth control to prevent unintended pregnancy.

(2) The federal Patient Protection and Affordable Care Act includes a contraceptive coverage guarantee as part of a broader requirement for health insurance to cover key preventive care services without out-of-pocket costs for patients.

(3) The General Assembly intends to build on existing State and federal law to promote gender equity and women's health and to ensure greater contraceptive coverage equity and timely access to all federal Food and Drug Administration approved methods of birth control for all individuals covered by an individual or group health insurance policy in Illinois.

(4) Medical management techniques such as denials, step therapy, or prior authorization in public and private health care coverage can impede access to the most effective contraceptive methods.

(b) As used in this Section:

"Contraceptive services" includes consultations, examinations, procedures, and medical services, provided on an outpatient basis and related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.

"Medical necessity" includes, but is not limited to, considerations such as severity of side effects, differences in permanence and reversibility of contraceptive, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider.

"Therapeutic equivalent version" means drugs, devices, or products that can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling and satisfy the following general criteria:

(1) they are approved as safe and effective;

(2) they are pharmaceutical equivalents in that they (A) contain identical amounts of the same active drug ingredient in the same dosage form and route of administration and (B) meet compendial or other applicable standards of strength, quality, purity, and identity;

(3) they are bioequivalent in that (A) they do not present a known or potential bioequivalence problem and they meet an acceptable in vitro standard or (B) if they do present such a known or potential problem, they are shown to meet an appropriate bioequivalence standard;

(4) they are adequately labeled; and

(5) they are manufactured in compliance with Current Good Manufacturing Practice regulations.

(c) (a) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State after the effective date of this amendatory Act of the 99th General Assembly shall provide coverage for all of the following services and contraceptive methods:

(1) All contraceptive drugs, devices, and other products approved by the United States Food and Drug Administration. This includes all over-the-counter contraceptive drugs, devices, and products approved by the United States Food and Drug Administration. The following apply:

(A) If the United States Food and Drug Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all such therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing and in accordance with this Section.

(B) If an individual's attending provider recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider.

(C) If a drug, device, or product is not covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or other individual acting as a patient's authorized representative to ensure coverage without cost sharing.

(D) This coverage must provide for the dispensing of 12 months' worth of contraception at one time.

(2) Voluntary sterilization procedures.

(3) Contraceptive services, patient education, and counseling on contraception.

(4) Follow-up services related to the drugs, devices, products, and procedures covered under this Section, including, but not limited to, management of side effects, counseling for continued adherence, and device insertion and removal.

(d) A policy subject to this Section shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided pursuant to this Section.

(e) Except as otherwise authorized under this Section, a policy shall not impose any restrictions or delays on the coverage required under this Section. this amendatory Act of the 93rd General Assembly that provides coverage for outpatient services and outpatient prescription drugs or devices must provide coverage for the insured and any dependent of the insured covered by the policy for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the Food and Drug Administration. Coverage required under this Section may not impose any deductible, coinsurance, waiting period, or other cost-sharing or limitation that is greater than that required for any outpatient service or outpatient prescription drug or device otherwise covered by the policy. (b) As used in this Section, "outpatient contraceptive service" means consultations, examinations, procedures, and medical services, provided on an outpatient basis and related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.

(f) (c) Nothing in this Section shall be construed to require an insurance company to cover services related to an abortion as the term "abortion" is defined in the Illinois Abortion Law of 1975.

(d) Nothing in this Section shall be construed to require an insurance company to cover services related to permanent sterilization that requires a surgical procedure.

(Source: P.A. 95-331, eff. 8-21-07.)