Rep. Greg Harris

Filed: 3/24/2011

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1191

2    AMENDMENT NO. ______. Amend House Bill 1191 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 364.01 as follows:
 
6    (215 ILCS 5/364.01)
7    Sec. 364.01. Qualified clinical cancer trials.
8    (a) No individual or group policy of accident and health
9insurance issued or renewed in this State may be cancelled or
10non-renewed for any individual based on that individual's
11participation in a qualified clinical cancer trial.
12    (b) Qualified clinical cancer trials must meet the
13following criteria:
14        (1) the effectiveness of the treatment has not been
15    determined relative to established therapies;
16        (2) the trial is under clinical investigation as part

 

 

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1    of an approved cancer research trial in Phase II, Phase
2    III, or Phase IV of investigation;
3        (3) the trial is:
4            (A) approved by the Food and Drug Administration;
5        or
6            (B) approved and funded by the National Institutes
7        of Health, the Centers for Disease Control and
8        Prevention, the Agency for Healthcare Research and
9        Quality, the United States Department of Defense, the
10        United States Department of Veterans Affairs, or the
11        United States Department of Energy in the form of an
12        investigational new drug application, or a cooperative
13        group or center of any entity described in this
14        subdivision (B); and
15        (4) the patient's primary care physician, if any, is
16    involved in the coordination of care.
17    (c) No group policy of accident and health insurance shall
18exclude coverage for any routine patient care administered to
19an insured who is a qualified individual participating in a
20qualified clinical cancer trial, if the policy covers that same
21routine patient care of insureds not enrolled in a qualified
22clinical cancer trial.
23    (d) The coverage that may not be excluded under subsection
24(c) of this Section is subject to all terms, conditions,
25restrictions, exclusions, and limitations that apply to the
26same routine patient care received by an insured not enrolled

 

 

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1in a qualified clinical cancer trial, including the application
2of any authorization requirement, utilization review, or
3medical management practices. The insured or enrollee shall
4incur no greater out-of-pocket liability than had the insured
5or enrollee not enrolled in a qualified clinical cancer trial.
6    (e) If the group policy of accident and health insurance
7uses a preferred provider program and a preferred provider
8provides routine patient care in connection with a qualified
9clinical cancer trial, then the insurer may require the insured
10to use the preferred provider if the preferred provider agrees
11to provide to the insured that routine patient care.
12    (f) A qualified clinical cancer trial may not pay or refuse
13to pay for routine patient care of an individual participating
14in the trial, based in whole or in part on the person's having
15or not having coverage for routine patient care under a group
16policy of accident and health insurance.
17    (g) Nothing in this Section shall be construed to limit an
18insurer's coverage with respect to clinical trials.
19    (h) Nothing in this Section shall require coverage for
20out-of-network services where the underlying health benefit
21plan does not provide coverage for out-of-network services.
22    (i) As used in this Section, "routine patient care" means
23all health care services provided in the qualified clinical
24cancer trial that are otherwise generally covered under the
25policy if those items or services were not provided in
26connection with a qualified clinical cancer trial consistent

 

 

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1with the standard of care for the treatment of cancer,
2including the type and frequency of any diagnostic modality,
3that a provider typically provides to a cancer patient who is
4not enrolled in a qualified clinical cancer trial. "Routine
5patient care" does not include, and a group policy of accident
6and health insurance may exclude, coverage for:
7        (1) a health care service, item, or drug that is the
8    subject of the cancer clinical trial;
9        (2) a health care service, item, or drug provided
10    solely to satisfy data collection and analysis needs for
11    the qualified clinical cancer trial that is not used in the
12    direct clinical management of the patient;
13        (3) an investigational drug or device that has not been
14    approved for market by the United States Food and Drug
15    Administration;
16        (4) transportation, lodging, food, or other expenses
17    for the patient or a family member or companion of the
18    patient that are associated with the travel to or from a
19    facility providing the qualified clinical cancer trial,
20    unless the policy covers these expenses for a cancer
21    patient who is not enrolled in a qualified clinical cancer
22    trial;
23        (5) a health care service, item, or drug customarily
24    provided by the qualified clinical cancer trial sponsors
25    free of charge for any patient;
26        (6) a health care service or item, which except for the

 

 

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1    fact that it is being provided in a qualified clinical
2    cancer trial, is otherwise specifically excluded from
3    coverage under the insured's policy, including:
4            (A) costs of extra treatments, services,
5        procedures, tests, or drugs that would not be performed
6        or administered except for the fact that the insured is
7        participating in the cancer clinical trial; and
8            (B) costs of nonhealth care services that the
9        patient is required to receive as a result of
10        participation in the approved cancer clinical trial;
11        (7) costs for services, items, or drugs that are
12    eligible for reimbursement from a source other than a
13    patient's contract or policy providing for third-party
14    payment or prepayment of health or medical expenses,
15    including the sponsor of the approved cancer clinical
16    trial; or
17        (8) costs associated with approved cancer clinical
18    trials designed exclusively to test toxicity or disease
19    pathophysiology, unless the policy covers these expenses
20    for a cancer patient who is not enrolled in a qualified
21    clinical cancer trial; or
22        (9) a health care service or item that is eligible for
23    reimbursement by a source other than the insured's policy,
24    including the sponsor of the qualified clinical cancer
25    trial.
26    The definitions of the terms "health care services",

 

 

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1"Non-Preferred Provider", "Preferred Provider", and "Preferred
2Provider Program", stated in 50 IL Adm. Code Part 2051
3Preferred Provider Programs apply to these terms in this
4Section.
5    (j) The external review procedures established under the
6Health Carrier External Review Act shall apply to the
7provisions under this Section.
8(Source: P.A. 93-1000, eff. 1-1-05.)
 
9    Section 99. Effective date. This Act takes effect January
101, 2012.".