State of Illinois
92nd General Assembly
Legislation

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92_SB1928

 
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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; Illinois  Insurance
 9    Code  requirements.   The  program  of  health benefits shall
10    provide the post-mastectomy  care  benefits  required  to  be
11    covered  by  a  policy of accident and health insurance under
12    Section 356t of the Illinois Insurance Code.  The program  of
13    health  benefits  shall  provide  the coverage required under
14    Sections  356u,  356w,  and  356x,  356z.2  of  the  Illinois
15    Insurance Code. The program of health  benefits  must  comply
16    with Section 155.37 of the Illinois Insurance Code.
17    (Source: P.A. 92-440, eff. 8-17-01.)

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

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

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

 9        (65 ILCS 5/10-4-2.3)
10        Sec.   10-4-2.3.    Required   health   benefits.   If  a
11    municipality,  including  a  home  rule  municipality,  is  a
12    self-insurer  for  purposes  of  providing  health  insurance
13    coverage  for  its  employees,  the  coverage  shall  include
14    coverage for the post-mastectomy care benefits required to be
15    covered by a policy of accident and  health  insurance  under
16    Section  356t  and the coverage required under Sections 356u,
17    356w, and 356x, and 356z.2 of the  Illinois  Insurance  Code.
18    The  requirement  that health benefits be covered as provided
19    in this is an exclusive power and function of the  State  and
20    is  a  denial  and  limitation  under Article VII, Section 6,
21    subsection (h) of the Illinois  Constitution.   A  home  rule
22    municipality  to  which this Section applies must comply with
23    every provision of this Section.
24    (Source: P.A. 90-7, eff. 6-10-97; 90-741, eff. 1-1-99.)

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

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

 5        Section 25.  The Illinois Insurance Code  is  amended  by
 6    adding Section 356z.2 as follows:

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

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

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

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

24        (215 ILCS 165/10) (from Ch. 32, par. 604)
25        Sec.  10.  Application  of  Insurance  Code   provisions.
26    Health  services plan corporations and all persons interested
27    therein  or  dealing  therewith  shall  be  subject  to   the
28    provisions of Articles IIA and XII 1/2 and Sections 3.1, 133,
29    140,  143,  143c,  149, 155.37, 354, 355.2, 356r, 356t, 356u,
30    356v, 356w, 356x, 356y, 356z.1,  356z.2,  367.2,  368a,  401,
31    401.1,  402,  403,  403A, 408, 408.2, and 412, and paragraphs
32    (7) and (15) of Section 367 of the Illinois Insurance Code.
 
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 1    (Source: P.A. 91-406,  eff.  1-1-00;  91-549,  eff.  8-14-99;
 2    91-605,  eff.  12-14-99;  91-788,  eff.  6-9-00; 92-130, eff.
 3    7-20-01; 92-440, eff. 8-17-01; revised 9-12-01.)

 4        Section 95.  The State Mandates Act is amended by  adding
 5    Section 8.26 as follows:

 6        (30 ILCS 805/8.26 new)
 7        Sec.  8.26.  Exempt  mandate.  Notwithstanding Sections 6
 8    and 8 of this Act, no reimbursement by the State is  required
 9    for  the  implementation  of  any  mandate  created  by  this
10    amendatory Act of the 92nd General Assembly.

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