State of Illinois
92nd General Assembly
Legislation

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92_SB0035

 
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 1        AN   ACT  concerning  insurance  coverage  for  pregnancy
 2    prevention, amending named Acts.

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

 5        Section  5.  The  State  Employees Group Insurance Act of
 6    1971 is amended by changing Section 6.11 as follows:

 7        (5 ILCS 375/6.11)
 8        Sec. 6.11.  Required health  benefits.   The  program  of
 9    health   benefits  shall  provide  the  post-mastectomy  care
10    benefits required to be covered by a policy of  accident  and
11    health insurance under Section 356t of the Illinois Insurance
12    Code.   The  program  of  health  benefits  shall provide the
13    coverage required under Sections 356u, 356w,  and  356x,  and
14    356z.1 of the Illinois Insurance Code.
15    (Source: P.A.  90-7,  eff.  6-10-97;  90-655,  eff.  7-30-98;
16    90-741, eff. 1-1-99.)

17        Section  10.  The  Counties  Code  is amended by changing
18    Section 5-1069.3 as follows:

19        (55 ILCS 5/5-1069.3)
20        Sec. 5-1069.3.  Required health benefits.  If  a  county,
21    including  a home rule county, is a self-insurer for purposes
22    of providing health insurance coverage for its employees, the
23    coverage shall include coverage for the post-mastectomy  care
24    benefits  required  to be covered by a policy of accident and
25    health insurance under Section 356t and the coverage required
26    under Sections 356u, 356w,  and  356x,  and  356z.1   of  the
27    Illinois   Insurance   Code.   The  requirement  that  health
28    benefits be  covered  as  provided  in  this  Section  is  an
29    exclusive power and function of the State and is a denial and
 
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 1    limitation  under  Article  VII, Section 6, subsection (h) of
 2    the Illinois Constitution.  A home rule county to which  this
 3    Section  applies  must  comply  with  every provision of this
 4    Section.
 5    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 6        Section 15.  The Illinois Municipal Code  is  amended  by
 7    changing Section 10-4-2.3 as follows:

 8        (65 ILCS 5/10-4-2.3)
 9        Sec.   10-4-2.3.    Required   health   benefits.   If  a
10    municipality,  including  a  home  rule  municipality,  is  a
11    self-insurer  for  purposes  of  providing  health  insurance
12    coverage  for  its  employees,  the  coverage  shall  include
13    coverage for the post-mastectomy care benefits required to be
14    covered by a policy of accident and  health  insurance  under
15    Section  356t  and the coverage required under Sections 356u,
16    356w, and 356x, and 356z.1 of the  Illinois  Insurance  Code.
17    The  requirement  that health benefits be covered as provided
18    in this is an exclusive power and function of the  State  and
19    is  a  denial  and  limitation  under Article VII, Section 6,
20    subsection (h) of the Illinois  Constitution.   A  home  rule
21    municipality  to  which this Section applies must comply with
22    every provision of this Section.
23    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

24        Section 20.  The  School  Code  is  amended  by  changing
25    Section 10-22.3f as follows:

26        (105 ILCS 5/10-22.3f)
27        Sec.   10-22.3f.  Required  health  benefits.   Insurance
28    protection and  benefits  for  employees  shall  provide  the
29    post-mastectomy  care  benefits  required  to be covered by a
30    policy of accident and health insurance  under  Section  356t
 
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 1    and  the  coverage  required  under  Sections 356u, 356w, and
 2    356x, and 356z.1 of the Illinois Insurance Code.
 3    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

 4        Section 25.  The Illinois Insurance Code  is  amended  by
 5    adding Section 356z.1 as follows:

 6        (215 ILCS 5/356z.1 new)
 7        Sec.  356z.1.  Clinical  cancer  trials;  routine patient
 8    care costs.
 9        (a)  For the purposes  of  this  Section,  the  following
10    terms have the following meanings:
11             (1)  "Clinical  or principal investigator" means the
12        person managing the clinical trial.
13             (2)  "Life threatening disease or condition" means a
14        disease or condition, which includes, but is not  limited
15        to,  breast  cancer,  prostate  cancer,  and leukemia, in
16        which either or both of the following is applicable:
17                  (A)  The likelihood of death is high unless the
18             course of the disease or condition is interrupted.
19                  (B)  The outcome is potentially fatal  and  the
20             purpose of clinical intervention is survival.
21             (3)  "Routine  patient  care  costs" means the costs
22        associated with the provision of items and services  that
23        would  otherwise  be  covered  under  the policy if those
24        items and services were not provided in  connection  with
25        an  approved clinical trial program. For purposes of this
26        Section, "routine patient care costs"  does  not  include
27        the  costs  associated  with  the provision of any of the
28        following:
29                  (A)  The cost of  an  investigational  drug  or
30             device.
31                  (B)  The  cost  of  services  other than health
32             care services that  an  insured  may  require  as  a
 
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 1             result  of the treatment being provided for purposes
 2             of the clinical trial.
 3                  (C)  The costs  associated  with  managing  the
 4             research associated with the clinical trial.
 5                  (D)  The  costs that would not be covered under
 6             the insured's coverage with  respect  to  a  medical
 7             procedure not involving a clinical trial.
 8        (b)  A  group or individual policy of accident and health
 9    insurance that is amended, delivered, issued, or  renewed  in
10    this State on and after the effective date of this amendatory
11    Act  of  the  92nd General Assembly must provide coverage for
12    routine patient care costs for an insured for treatment in  a
13    Phase  II  through  Phase  III  clinical trial that meets the
14    requirements  of  this  Section,  if  all  of  the  following
15    conditions are met:
16             (1)  the  treatment  is   being   provided   for   a
17        life-threatening  disease or  condition;
18             (2)  the      insured's     physician     recommends
19        participation in the clinical trial; and
20             (3)  the  insured's  physician  certifies  that  the
21        clinical trial is likely to be more  beneficial  for  the
22        insured than any available standard therapy.
23        (c)  The  treatment shall be provided in a clinical trial
24    approved by one of the following:
25             (1)  One of the National Institutes of Health.
26             (2)  The federal Food and  Drug  Administration,  in
27        the form of an investigational new drug application.
28             (3)  The Department of Defense.
29        (d)  In  the  case of routine patient care costs provided
30    by a participating provider, the payment rate shall be at the
31    agreed upon rate. In the case of a nonparticipating provider,
32    the payment rate shall be at the rate the insurer  would  pay
33    to  a participating provider for comparable services. Nothing
34    in this Section shall be construed  to  prohibit  an  insurer
 
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 1    from    restricting   coverage   for   clinical   trials   to
 2    participating hospitals and physicians in Illinois unless the
 3    protocol for the clinical trial is not  provided  for  at  an
 4    Illinois hospital or by an Illinois physician.
 5        (e)  The   clinical  or  principal  investigator  seeking
 6    coverage on behalf of an insured for treatment in a  clinical
 7    trial   approved   pursuant  to  subsection  (c)  shall  post
 8    electronically on the National  Cancer  Institute's  national
 9    physician data query data base a current list of the clinical
10    trials  for which he or she is seeking coverage and that meet
11    the requirements of subsection (b).
12        This information shall also be provided to the  insured's
13    insurer.
14        The  list  shall include, for each clinical trial, all of
15    the following:
16             (1)  The name of the trial.
17             (2)  The phase of the trial.
18             (3)  The disease being treated by the trial.
19             (4)  The method by which further  information  about
20        the trial may be obtained.
21        (f)  On  or  before June 1 of each year, an insurer shall
22    submit a report to the Director, in a form  required  by  the
23    Director, that describes the clinical trials that the insurer
24    covered  with  respect  to  an  insured.  The  Director shall
25    compile an annual  summary  report.  A  copy  of  the  annual
26    summary  report  shall be provided to the Governor and to the
27    General Assembly.

28        Section 30.  The Health Maintenance Organization  Act  is
29    amended by changing Section 5-3 as follows:

30        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
31        Sec. 5-3.  Insurance Code provisions.
32        (a)  Health Maintenance Organizations shall be subject to
 
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 1    the  provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
 2    141.3, 143, 143c, 147, 148, 149, 151, 152, 153,  154,  154.5,
 3    154.6,  154.7,  154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
 4    356y, 356z.1, 367i, 368a, 401, 401.1, 402,  403,  403A,  408,
 5    408.2,  409, 412, 444, and 444.1, paragraph (c) of subsection
 6    (2) of Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2,
 7    XIII, XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
 8        (b)  For purposes of the Illinois Insurance Code,  except
 9    for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
10    Health Maintenance Organizations in the following  categories
11    are deemed to be "domestic companies":
12             (1)  a   corporation  authorized  under  the  Dental
13        Service Plan Act or the Voluntary Health  Services  Plans
14        Act;
15             (2)  a  corporation organized under the laws of this
16        State; or
17             (3)  a  corporation  organized  under  the  laws  of
18        another state, 30% or more of the enrollees of which  are
19        residents  of this State, except a corporation subject to
20        substantially the  same  requirements  in  its  state  of
21        organization  as  is  a  "domestic company" under Article
22        VIII 1/2 of the Illinois Insurance Code.
23        (c)  In considering the merger, consolidation,  or  other
24    acquisition  of  control of a Health Maintenance Organization
25    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
26             (1)  the Director shall give  primary  consideration
27        to  the  continuation  of  benefits  to enrollees and the
28        financial conditions of the acquired  Health  Maintenance
29        Organization  after  the  merger, consolidation, or other
30        acquisition of control takes effect;
31             (2)(i)  the criteria specified in subsection  (1)(b)
32        of Section 131.8 of the Illinois Insurance Code shall not
33        apply  and (ii) the Director, in making his determination
34        with respect  to  the  merger,  consolidation,  or  other
 
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 1        acquisition  of  control,  need not take into account the
 2        effect on competition of the  merger,  consolidation,  or
 3        other acquisition of control;
 4             (3)  the  Director  shall  have the power to require
 5        the following information:
 6                  (A)  certification by an independent actuary of
 7             the  adequacy  of  the  reserves   of   the   Health
 8             Maintenance Organization sought to be acquired;
 9                  (B)  pro  forma financial statements reflecting
10             the combined balance sheets of the acquiring company
11             and the Health Maintenance Organization sought to be
12             acquired as of the end of the preceding year and  as
13             of  a date 90 days prior to the acquisition, as well
14             as  pro  forma   financial   statements   reflecting
15             projected  combined  operation  for  a  period  of 2
16             years;
17                  (C)  a pro forma  business  plan  detailing  an
18             acquiring   party's   plans   with  respect  to  the
19             operation of  the  Health  Maintenance  Organization
20             sought  to be acquired for a period of not less than
21             3 years; and
22                  (D)  such other  information  as  the  Director
23             shall require.
24        (d)  The  provisions  of Article VIII 1/2 of the Illinois
25    Insurance Code and this Section 5-3 shall apply to  the  sale
26    by any health maintenance organization of greater than 10% of
27    its  enrollee  population  (including  without limitation the
28    health maintenance organization's right, title, and  interest
29    in and to its health care certificates).
30        (e)  In  considering  any  management contract or service
31    agreement subject to Section 141.1 of the Illinois  Insurance
32    Code,  the  Director  (i)  shall, in addition to the criteria
33    specified in Section 141.2 of the  Illinois  Insurance  Code,
34    take  into  account  the effect of the management contract or
 
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 1    service  agreement  on  the  continuation  of   benefits   to
 2    enrollees   and   the   financial  condition  of  the  health
 3    maintenance organization to be managed or serviced, and  (ii)
 4    need  not  take  into  account  the  effect of the management
 5    contract or service agreement on competition.
 6        (f)  Except for small employer groups as defined  in  the
 7    Small  Employer  Rating,  Renewability and Portability Health
 8    Insurance Act and except for medicare supplement policies  as
 9    defined  in  Section  363  of  the Illinois Insurance Code, a
10    Health Maintenance Organization may by contract agree with  a
11    group  or  other  enrollment unit to effect refunds or charge
12    additional premiums under the following terms and conditions:
13             (i)  the amount of, and other terms  and  conditions
14        with respect to, the refund or additional premium are set
15        forth  in the group or enrollment unit contract agreed in
16        advance of the period for which a refund is to be paid or
17        additional premium is to be charged (which  period  shall
18        not be less than one year); and
19             (ii)  the amount of the refund or additional premium
20        shall   not   exceed   20%   of  the  Health  Maintenance
21        Organization's profitable or unprofitable experience with
22        respect to the group or other  enrollment  unit  for  the
23        period  (and,  for  purposes  of  a  refund or additional
24        premium, the profitable or unprofitable experience  shall
25        be calculated taking into account a pro rata share of the
26        Health   Maintenance  Organization's  administrative  and
27        marketing expenses, but shall not include any  refund  to
28        be made or additional premium to be paid pursuant to this
29        subsection (f)).  The Health Maintenance Organization and
30        the   group   or  enrollment  unit  may  agree  that  the
31        profitable or unprofitable experience may  be  calculated
32        taking into account the refund period and the immediately
33        preceding 2 plan years.
34        The  Health  Maintenance  Organization  shall  include  a
 
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 1    statement in the evidence of coverage issued to each enrollee
 2    describing the possibility of a refund or additional premium,
 3    and  upon request of any group or enrollment unit, provide to
 4    the group or enrollment unit a description of the method used
 5    to  calculate  (1)  the  Health  Maintenance   Organization's
 6    profitable experience with respect to the group or enrollment
 7    unit and the resulting refund to the group or enrollment unit
 8    or  (2)  the  Health  Maintenance Organization's unprofitable
 9    experience with respect to the group or enrollment  unit  and
10    the  resulting  additional premium to be paid by the group or
11    enrollment unit.
12        In  no  event  shall  the  Illinois  Health   Maintenance
13    Organization  Guaranty  Association  be  liable  to  pay  any
14    contractual  obligation  of  an insolvent organization to pay
15    any refund authorized under this Section.
16    (Source: P.A.  90-25,  eff.  1-1-98;  90-177,  eff.  7-23-97;
17    90-372, eff.  7-1-98;  90-583,  eff.  5-29-98;  90-655,  eff.
18    7-30-98;  90-741,  eff. 1-1-99; 91-357, eff. 7-29-99; 91-406,
19    eff. 1-1-00; 91-549, eff.  8-14-99;  91-605,  eff.  12-14-99;
20    91-788, eff. 6-9-00.)

21        Section  35.  The  Voluntary Health Services Plans Act is
22    amended by changing Section 10 as follows:

23        (215 ILCS 165/10) (from Ch. 32, par. 604)
24        Sec.  10.  Application  of  Insurance  Code   provisions.
25    Health  services plan corporations and all persons interested
26    therein  or  dealing  therewith  shall  be  subject  to   the
27    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
28    140,  143,  143c,  149,  354,  355.2, 356r, 356t, 356u, 356v,
29    356w, 356x, 356y, 356z.1, 367.2, 368a, 401, 401.1, 402,  403,
30    403A,  408,  408.2,  and  412, and paragraphs (7) and (15) of
31    Section 367 of the Illinois Insurance Code.
32    (Source: P.A. 90-7, eff. 6-10-97; 90-25, eff. 1-1-98; 90-655,
 
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 1    eff. 7-30-98;  90-741,  eff.  1-1-99;  91-406,  eff.  1-1-00;
 2    91-549,  eff.  8-14-99;  91-605,  eff. 12-14-99; 91-788, eff.
 3    6-9-00.)

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