101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB5230

 

Introduced , by Rep. Michael D. Unes

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.43 new

    Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2021 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with intensity modulated radiation therapy for the same indication if specified conditions are satisfied. Provides standards concerning the aggregate amount chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy. Provides that proton therapy coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract. Defines terms. Effective January 1, 2021.


LRB101 18346 BMS 67793 b

 

 

A BILL FOR

 

HB5230LRB101 18346 BMS 67793 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 356z.43 as follows:
 
6    (215 ILCS 5/356z.43 new)
7    Sec. 356z.43. Proton therapy access.
8    (a) As used in this Section:
9    "Aggregate amount" means the total amount paid under an
10individual or group policy of accident and health insurance for
11the applicable radiation treatment delivery current procedural
12terminology codes to deliver a biological effective dose.
13    "Biological effective dose" means the total prescribed
14radiation dose delivered in a course of radiation therapy
15treatments to induce tumor cell death.
16    "Current procedural terminology code" means the unique
17numerical designations established by the American Medical
18Association for various medical, surgical, and diagnostic
19services used in billing health care services.
20    "Eligible patient" means a cancer patient who is approved
21for a standard radiation therapy protocol delivered with IMRT
22and prescribed a hypofractionated proton therapy protocol for
23the treatment of the same cancer.

 

 

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1    "Hypofractionated proton therapy protocol" means a cancer
2treatment protocol that involves the delivery of fewer, larger
3radiation therapy treatment doses than a standard radiation
4therapy protocol to deliver a biological effective dose.
5    "Intensity modulated radiation therapy" or "IMRT" means a
6type of conformal radiation therapy that delivers x-ray
7radiation beams of different intensities from many angles for
8the treatment of tumors.
9    "Proton therapy" means the advanced form of radiation
10therapy that utilizes protons as the radiation delivery method
11for the treatment of tumors.
12    "Radiation therapy" means the delivery of a biological
13effective dose with proton therapy, IMRT, brachytherapy,
14stereotactic body radiation therapy, three-dimensional
15conformal radiation therapy, or other forms of therapy using
16radiation.
17    "Registry" means an organized system that uses
18observational study methods to collect uniform clinical data to
19evaluate specified outcomes for a population defined by a
20particular disease and is compliant with the principles
21established by the Registries for Evaluating Patient Outcomes:
22A User's Guide - Third Edition published by the Agency for
23Healthcare Research and Quality of the U.S. Department of
24Health and Human Services.
25    "Standard radiation therapy protocol" means a cancer
26treatment protocol that involves the delivery of radiation

 

 

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1therapy treatment doses over an extended period of time to
2deliver a biological effective dose.
3    "Treatment dose" means the amount of radiation delivered in
4a single treatment or fraction of radiation therapy.
5    (b) An individual or group policy of accident and health
6insurance that is amended, delivered, issued, or renewed on or
7after January 1, 2021 shall cover a medically necessary
8hypofractionated proton therapy protocol to deliver a
9biological effective dose by paying the same aggregate amount
10as would be paid for the delivery of the same biological
11effective dose with a standard radiation therapy protocol
12delivered with IMRT for the same indication if the following
13conditions are satisfied:
14        (1) coverage is provided to an eligible patient who is
15    being treated as part of a clinical trial or registry;
16        (2) the eligible patient is diagnosed with a cancer
17    type or indication that can be treated with a
18    hypofractionated proton therapy protocol; and
19        (3) the radiation oncologist prescribing the
20    hypofractionated proton therapy protocol is board
21    certified or board eligible in the specialty of radiation
22    oncology.
23    (c) If coverage of a hypofractionated proton therapy
24protocol is required pursuant to subsection (b), then:
25        (1) the aggregate amount must be equal to the average
26    cost actually paid by an individual or group policy of

 

 

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1    accident and health insurance for a standard radiation
2    therapy protocol delivered with IMRT required to deliver
3    the prescribed biological effective dose for the
4    particular indication. For the purposes of this paragraph
5    (1), aggregate amounts must be established by reference to
6    the amount paid for a course of IMRT treatment under a
7    standard radiation therapy protocol delivered with IMRT
8    for the indication under the applicable policy; and
9        (2) coverage may not impose an annual deductible,
10    coinsurance, or other cost-sharing limitation that is
11    greater than that required for radiation therapy and other
12    similar benefits within the insurance policy or contract.
13    (d) Notwithstanding any other provision of this Section to
14the contrary, the aggregate amount:
15        (1) reimbursed for the hypofractionated proton therapy
16    protocol must not exceed the average aggregate amount paid
17    by an individual or group policy of accident and health
18    insurance for a course of IMRT treatment under a standard
19    radiation therapy protocol delivered with IMRT to deliver
20    the prescribed biological effective dose for the same
21    indication;
22        (2) chargeable to or payable by an eligible patient for
23    a covered course of hypofractionated proton therapy by an
24    in-network provider must not exceed the aggregate amount
25    that would otherwise be chargeable to or payable by the
26    eligible patient for a course of IMRT treatment under a

 

 

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1    standard radiation therapy protocol delivered with IMRT
2    that is covered by the applicable policy for the delivery
3    of the same biological effective dose by an in-network
4    provider; and
5        (3) chargeable to or payable by an eligible patient for
6    a covered course of hypofractionated proton therapy by an
7    out-of-network provider must not exceed the aggregate
8    amount that would otherwise be chargeable to or payable by
9    the eligible patient for a course of treatment under a
10    standard radiation therapy protocol delivered with IMRT
11    that is covered by the applicable policy for the delivery
12    of the same biological effective dose by an out-of-network
13    provider. However, the patient is not responsible for
14    amounts greater than the allowable maximum charge.
 
15    Section 99. Effective date. This Act takes effect January
161, 2021.