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92_SB1928 LRB9215996JSpc 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,and356x, 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,and356x, and 356z.2 of the 28 Illinois Insurance Code. The requirement that health 29 benefits be covered as provided in this Section is an -2- LRB9215996JSpc 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,and356x, 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 -3- LRB9215996JSpc 1 policy of accident and health insurance under Section 356t 2 and the coverage required under Sections 356u, 356w,and3 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 -4- LRB9215996JSpc 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 -5- LRB9215996JSpc 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. -6- LRB9215996JSpc 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 -7- LRB9215996JSpc 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, -8- LRB9215996JSpc 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. -9- LRB9215996JSpc 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. -10- LRB9215996JSpc 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.