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92_SB0035 LRB9201077JSpc 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,and356x, 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,and356x, 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 -2- LRB9201077JSpc 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,and356x, 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 -3- LRB9201077JSpc 1 and the coverage required under Sections 356u, 356w,and2 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 -4- LRB9201077JSpc 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 -5- LRB9201077JSpc 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 -6- LRB9201077JSpc 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 -7- LRB9201077JSpc 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 -8- LRB9201077JSpc 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 -9- LRB9201077JSpc 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, -10- LRB9201077JSpc 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.)