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Public Act 097-0091


 

Public Act 0091 97TH GENERAL ASSEMBLY



 


 
Public Act 097-0091
 
HB1191 EnrolledLRB097 06572 RPM 46657 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Sections 356z.16 and 364.01 as follows:
 
    (215 ILCS 5/356z.16)
    Sec. 356z.16. Applicability of mandated benefits to
supplemental policies. Unless specified otherwise, the
following Sections of the Illinois Insurance Code do not apply
to short-term travel, disability income, long-term care,
accident only, or limited or specified disease policies: 356b,
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t,
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
356z.8, 356z.12, 364.01, 367.2-5, and 367e.
(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10;
96-1034, eff. 1-1-11.)
 
    (215 ILCS 5/364.01)
    Sec. 364.01. Qualified clinical cancer trials.
    (a) No individual or group policy of accident and health
insurance issued or renewed in this State may be cancelled or
non-renewed for any individual based on that individual's
participation in a qualified clinical cancer trial.
    (b) Qualified clinical cancer trials must meet the
following criteria:
        (1) the effectiveness of the treatment has not been
    determined relative to established therapies;
        (2) the trial is under clinical investigation as part
    of an approved cancer research trial in Phase II, Phase
    III, or Phase IV of investigation;
        (3) the trial is:
            (A) approved by the Food and Drug Administration;
        or
            (B) approved and funded by the National Institutes
        of Health, the Centers for Disease Control and
        Prevention, the Agency for Healthcare Research and
        Quality, the United States Department of Defense, the
        United States Department of Veterans Affairs, or the
        United States Department of Energy in the form of an
        investigational new drug application, or a cooperative
        group or center of any entity described in this
        subdivision (B); and
        (4) the patient's primary care physician, if any, is
    involved in the coordination of care.
    (c) No group policy of accident and health insurance shall
exclude coverage for any routine patient care administered to
an insured who is a qualified individual participating in a
qualified clinical cancer trial, if the policy covers that same
routine patient care of insureds not enrolled in a qualified
clinical cancer trial.
    (d) The coverage that may not be excluded under subsection
(c) of this Section is subject to all terms, conditions,
restrictions, exclusions, and limitations that apply to the
same routine patient care received by an insured not enrolled
in a qualified clinical cancer trial, including the application
of any authorization requirement, utilization review, or
medical management practices. The insured or enrollee shall
incur no greater out-of-pocket liability than had the insured
or enrollee not enrolled in a qualified clinical cancer trial.
    (e) If the group policy of accident and health insurance
uses a preferred provider program and a preferred provider
provides routine patient care in connection with a qualified
clinical cancer trial, then the insurer may require the insured
to use the preferred provider if the preferred provider agrees
to provide to the insured that routine patient care.
    (f) A qualified clinical cancer trial may not pay or refuse
to pay for routine patient care of an individual participating
in the trial, based in whole or in part on the person's having
or not having coverage for routine patient care under a group
policy of accident and health insurance.
    (g) Nothing in this Section shall be construed to limit an
insurer's coverage with respect to clinical trials.
    (h) Nothing in this Section shall require coverage for
out-of-network services where the underlying health benefit
plan does not provide coverage for out-of-network services.
    (i) As used in this Section, "routine patient care" means
all health care services provided in the qualified clinical
cancer trial that are otherwise generally covered under the
policy if those items or services were not provided in
connection with a qualified clinical cancer trial consistent
with the standard of care for the treatment of cancer,
including the type and frequency of any diagnostic modality,
that a provider typically provides to a cancer patient who is
not enrolled in a qualified clinical cancer trial. "Routine
patient care" does not include, and a group policy of accident
and health insurance may exclude, coverage for:
        (1) a health care service, item, or drug that is the
    subject of the cancer clinical trial;
        (2) a health care service, item, or drug provided
    solely to satisfy data collection and analysis needs for
    the qualified clinical cancer trial that is not used in the
    direct clinical management of the patient;
        (3) an investigational drug or device that has not been
    approved for market by the United States Food and Drug
    Administration;
        (4) transportation, lodging, food, or other expenses
    for the patient or a family member or companion of the
    patient that are associated with the travel to or from a
    facility providing the qualified clinical cancer trial,
    unless the policy covers these expenses for a cancer
    patient who is not enrolled in a qualified clinical cancer
    trial;
        (5) a health care service, item, or drug customarily
    provided by the qualified clinical cancer trial sponsors
    free of charge for any patient;
        (6) a health care service or item, which except for the
    fact that it is being provided in a qualified clinical
    cancer trial, is otherwise specifically excluded from
    coverage under the insured's policy, including:
            (A) costs of extra treatments, services,
        procedures, tests, or drugs that would not be performed
        or administered except for the fact that the insured is
        participating in the cancer clinical trial; and
            (B) costs of nonhealth care services that the
        patient is required to receive as a result of
        participation in the approved cancer clinical trial;
        (7) costs for services, items, or drugs that are
    eligible for reimbursement from a source other than a
    patient's contract or policy providing for third-party
    payment or prepayment of health or medical expenses,
    including the sponsor of the approved cancer clinical
    trial; or
        (8) costs associated with approved cancer clinical
    trials designed exclusively to test toxicity or disease
    pathophysiology, unless the policy covers these expenses
    for a cancer patient who is not enrolled in a qualified
    clinical cancer trial; or
        (9) a health care service or item that is eligible for
    reimbursement by a source other than the insured's policy,
    including the sponsor of the qualified clinical cancer
    trial.
    The definitions of the terms "health care services",
"Non-Preferred Provider", "Preferred Provider", and "Preferred
Provider Program", stated in 50 IL Adm. Code Part 2051
Preferred Provider Programs apply to these terms in this
Section.
    (j) The external review procedures established under the
Health Carrier External Review Act shall apply to the
provisions under this Section.
(Source: P.A. 93-1000, eff. 1-1-05.)
 
    Section 99. Effective date. This Act takes effect January
1, 2012.

Effective Date: 1/1/2012