97TH GENERAL ASSEMBLY
State of Illinois
2011 and 2012
HB2951

 

Introduced 2/23/2011, by Rep. Jehan A. Gordon

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/356z.19 new
215 ILCS 125/5-3  from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10  from Ch. 32, par. 604

    Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Illinois Insurance Code, Health Maintenance Organization Act, and Voluntary Health Services Plans Act. Provides that accident and health insurance policies and managed care plans must provide coverage for routine patient care costs incurred for cancer treatment in an approved cancer clinical trial to the same extent that such policy or contract provides coverage for treating any other sickness, injury, disease, or condition covered under the policy or contract if the insured has been referred for such cancer treatment. Sets forth criteria under which routine patient care costs for cancer treatment given pursuant to an approved cancer clinical trial shall be covered. Sets forth definitions for "approved cancer clinical trial", "institutional review board", "routine patient care costs", and "therapeutic intent". Effective on January 1, 2012.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning insurance.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Section 6.11 as follows:
 
6    (5 ILCS 375/6.11)
7    Sec. 6.11. Required health benefits; Illinois Insurance
8Code requirements. The program of health benefits shall provide
9the post-mastectomy care benefits required to be covered by a
10policy of accident and health insurance under Section 356t of
11the Illinois Insurance Code. The program of health benefits
12shall provide the coverage required under Sections 356g,
13356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
14356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
15356z.14, 356z.15, and 356z.17, and 356z.19 of the Illinois
16Insurance Code. The program of health benefits must comply with
17Section 155.37 of the Illinois Insurance Code.
18    Rulemaking authority to implement Public Act 95-1045, if
19any, is conditioned on the rules being adopted in accordance
20with all provisions of the Illinois Administrative Procedure
21Act and all rules and procedures of the Joint Committee on
22Administrative Rules; any purported rule not so adopted, for
23whatever reason, is unauthorized.

 

 

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1(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
295-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
36-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1044,
4eff. 3-26-09; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
596-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10;
696-1000, eff. 7-2-10.)
 
7    Section 10. The Counties Code is amended by changing
8Section 5-1069.3 as follows:
 
9    (55 ILCS 5/5-1069.3)
10    Sec. 5-1069.3. Required health benefits. If a county,
11including a home rule county, is a self-insurer for purposes of
12providing health insurance coverage for its employees, the
13coverage shall include coverage for the post-mastectomy care
14benefits required to be covered by a policy of accident and
15health insurance under Section 356t and the coverage required
16under Sections 356g, 356g.5, 356g.5-1, 356u, 356w, 356x,
17356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
18356z.14, and 356z.15, and 356z.19 of the Illinois Insurance
19Code. The requirement that health benefits be covered as
20provided in this Section is an exclusive power and function of
21the State and is a denial and limitation under Article VII,
22Section 6, subsection (h) of the Illinois Constitution. A home
23rule county to which this Section applies must comply with
24every provision of this Section.

 

 

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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
895-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
96-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
10eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1196-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
12    Section 15. The Illinois Municipal Code is amended by
13changing Section 10-4-2.3 as follows:
 
14    (65 ILCS 5/10-4-2.3)
15    Sec. 10-4-2.3. Required health benefits. If a
16municipality, including a home rule municipality, is a
17self-insurer for purposes of providing health insurance
18coverage for its employees, the coverage shall include coverage
19for the post-mastectomy care benefits required to be covered by
20a policy of accident and health insurance under Section 356t
21and the coverage required under Sections 356g, 356g.5,
22356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
23356z.11, 356z.12, 356z.13, 356z.14, and 356z.15, and 356z.19 of
24the Illinois Insurance Code. The requirement that health

 

 

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1benefits be covered as provided in this is an exclusive power
2and function of the State and is a denial and limitation under
3Article VII, Section 6, subsection (h) of the Illinois
4Constitution. A home rule municipality to which this Section
5applies must comply with every provision of this Section.
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1395-520, eff. 8-28-07; 95-876, eff. 8-21-08; 95-958, eff.
146-1-09; 95-978, eff. 1-1-09; 95-1005, eff. 12-12-08; 95-1045,
15eff. 3-27-09; 95-1049, eff. 1-1-10; 96-139, eff. 1-1-10;
1696-328, eff. 8-11-09; 96-1000, eff. 7-2-10.)
 
17    Section 20. The School Code is amended by changing Section
1810-22.3f as follows:
 
19    (105 ILCS 5/10-22.3f)
20    Sec. 10-22.3f. Required health benefits. Insurance
21protection and benefits for employees shall provide the
22post-mastectomy care benefits required to be covered by a
23policy of accident and health insurance under Section 356t and
24the coverage required under Sections 356g, 356g.5, 356g.5-1,

 

 

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1356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
2356z.13, 356z.14, and 356z.15, and 356z.19 of the Illinois
3Insurance Code.
4    Rulemaking authority to implement Public Act 95-1045, if
5any, is conditioned on the rules being adopted in accordance
6with all provisions of the Illinois Administrative Procedure
7Act and all rules and procedures of the Joint Committee on
8Administrative Rules; any purported rule not so adopted, for
9whatever reason, is unauthorized.
10(Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
1195-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
1295-1005, 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
131-1-10; 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; 96-1000,
14eff. 7-2-10.)
 
15    Section 25. The Illinois Insurance Code is amended by
16adding Section 356z.19 as follows:
 
17    (215 ILCS 5/356z.19 new)
18    Sec. 356z.19. Approved cancer clinical trials.
19    (a) A group or individual policy of accident and health
20insurance or managed care plan that is amended, delivered,
21issued, or renewed after the effective date of this amendatory
22Act of the 97th General Assembly must provide coverage for
23routine patient care costs incurred for cancer treatment in an
24approved cancer clinical trial to the same extent that such

 

 

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1policy or contract provides coverage for treating any other
2sickness, injury, disease, or condition covered under the
3policy or contract if the insured has been referred for such
4cancer treatment by 2 physicians who specialize in oncology and
5the cancer treatment is given pursuant to an approved cancer
6clinical trial that meets the criteria set forth in subsection
7(b) of this Section. Services that are furnished without charge
8to a participant in the approved cancer clinical trial are not
9required to be covered as routine patient care costs pursuant
10to this Section.
11    (b) Routine patient care costs for cancer treatment given
12pursuant to an approved cancer clinical trial shall be covered
13pursuant to this Section if all of the following requirements
14are met:
15        (1) The treatment is provided with therapeutic intent
16    and is provided pursuant to an approved cancer clinical
17    trial that has been authorized or approved by the National
18    Institutes of Health, the United States Food and Drug
19    Administration, the United States Department of Defense,
20    the United States Department of Veterans Affairs, the
21    United States Department of Energy, the Centers for Disease
22    Control and Prevention, or the Agency for Healthcare
23    Research and Quality.
24        (2) The proposed treatment has been reviewed and
25    approved by the applicable qualified institutional review
26    board.

 

 

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1        (3) The available clinical or preclinical data
2    indicate that the treatment that shall be provided pursuant
3    to the approved cancer clinical trial shall be at least as
4    effective as the standard therapy and is anticipated to
5    constitute an improvement in therapeutic effectiveness for
6    the treatment of the disease in question.
7    (c) For purposes of this Section:
8    "Approved cancer clinical trial" means a scientific study
9of a new therapy for the treatment of cancer in human beings
10that meets the requirements set forth in subsection (b) of this
11Section and consists of a scientific plan of treatment that
12includes specified goals, a rationale and background for the
13plan, criteria for patient selection, specific directions for
14administering therapy and monitoring patients, a definition of
15quantitative measures for determining treatment response, and
16methods for documenting and treating adverse reactions.
17    "Institutional review board" means a board, committee, or
18other group formally designated by an institution and approved
19by the National Institutes of Health, Office of Human Subjects
20Research to review, approve the initiation of, and conduct
21periodic review of biomedical research involving human
22subjects. "Institutional review board" has the same meaning as
23"institutional review committee" as used in section 520(g) of
24the federal Food, Drug, and Cosmetic Act, as codified in 21
25U.S.C. § 301 et seq.
26    "Routine patient care costs" means medically necessary

 

 

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1services or treatments that are a benefit under a contract or
2policy providing for third-party payment or prepayment of
3health or medical expenses that would be covered if the patient
4were receiving standard cancer treatment. "Routine patient
5care costs" does not include any of the following:
6        (1) Costs of any treatments, procedures, drugs,
7    devices, services, or items that are the subject of the
8    approved cancer clinical trial or any other
9    investigational treatments, procedures, drugs, devices,
10    services, or items.
11        (2) Costs of non-health care services that the patient
12    is required to receive as a result of participation in the
13    approved cancer clinical trial.
14        (3) Costs associated with managing the research that is
15    associated with the approved cancer clinical trial.
16        (4) Costs that would not be covered by the third-party
17    payment provider if non-investigational treatments were
18    provided.
19        (5) Costs of any services, procedures, or tests
20    provided solely to satisfy data collection and analysis
21    needs that are not used in the direct clinical management
22    of the patient participating in an approved cancer clinical
23    trial.
24        (6) Costs paid for, or not charged for, by the approved
25    cancer clinical trial providers.
26        (7) Costs for transportation, lodging, food, or other

 

 

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1    expenses for the patient, a family member, or a companion
2    of the patient that are associated with travel to or from a
3    facility where an approved cancer clinical trial is
4    conducted.
5        (8) Costs for services, items, or drugs that are
6    eligible for reimbursement from a source other than a
7    patient's contract or policy providing for third-party
8    payment or prepayment of health or medical expenses,
9    including the sponsor of the approved cancer clinical
10    trial.
11        (9) Costs associated with approved cancer clinical
12    trials designed exclusively to test toxicity or disease
13    pathophysiology.
14        (10) Costs of extra treatments, services, procedures,
15    tests, or drugs that would not be performed or administered
16    except for participation in the cancer clinical trial.
17    "Therapeutic intent" means that a treatment is aimed at
18improving a patient's health outcome relative to either
19survival or quality of life.
 
20    Section 30. The Health Maintenance Organization Act is
21amended by changing Section 5-3 as follows:
 
22    (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
23    Sec. 5-3. Insurance Code provisions.
24    (a) Health Maintenance Organizations shall be subject to

 

 

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1the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
2141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
3154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
4356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
5356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
6356z.18, 356z.19, 364.01, 367.2, 367.2-5, 367i, 368a, 368b,
7368c, 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2,
8409, 412, 444, and 444.1, paragraph (c) of subsection (2) of
9Section 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
10XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
11    (b) For purposes of the Illinois Insurance Code, except for
12Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
13Maintenance Organizations in the following categories are
14deemed to be "domestic companies":
15        (1) a corporation authorized under the Dental Service
16    Plan Act or the Voluntary Health Services Plans Act;
17        (2) a corporation organized under the laws of this
18    State; or
19        (3) a corporation organized under the laws of another
20    state, 30% or more of the enrollees of which are residents
21    of this State, except a corporation subject to
22    substantially the same requirements in its state of
23    organization as is a "domestic company" under Article VIII
24    1/2 of the Illinois Insurance Code.
25    (c) In considering the merger, consolidation, or other
26acquisition of control of a Health Maintenance Organization

 

 

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1pursuant to Article VIII 1/2 of the Illinois Insurance Code,
2        (1) the Director shall give primary consideration to
3    the continuation of benefits to enrollees and the financial
4    conditions of the acquired Health Maintenance Organization
5    after the merger, consolidation, or other acquisition of
6    control takes effect;
7        (2)(i) the criteria specified in subsection (1)(b) of
8    Section 131.8 of the Illinois Insurance Code shall not
9    apply and (ii) the Director, in making his determination
10    with respect to the merger, consolidation, or other
11    acquisition of control, need not take into account the
12    effect on competition of the merger, consolidation, or
13    other acquisition of control;
14        (3) the Director shall have the power to require the
15    following information:
16            (A) certification by an independent actuary of the
17        adequacy of the reserves of the Health Maintenance
18        Organization sought to be acquired;
19            (B) pro forma financial statements reflecting the
20        combined balance sheets of the acquiring company and
21        the Health Maintenance Organization sought to be
22        acquired as of the end of the preceding year and as of
23        a date 90 days prior to the acquisition, as well as pro
24        forma financial statements reflecting projected
25        combined operation for a period of 2 years;
26            (C) a pro forma business plan detailing an

 

 

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1        acquiring party's plans with respect to the operation
2        of the Health Maintenance Organization sought to be
3        acquired for a period of not less than 3 years; and
4            (D) such other information as the Director shall
5        require.
6    (d) The provisions of Article VIII 1/2 of the Illinois
7Insurance Code and this Section 5-3 shall apply to the sale by
8any health maintenance organization of greater than 10% of its
9enrollee population (including without limitation the health
10maintenance organization's right, title, and interest in and to
11its health care certificates).
12    (e) In considering any management contract or service
13agreement subject to Section 141.1 of the Illinois Insurance
14Code, the Director (i) shall, in addition to the criteria
15specified in Section 141.2 of the Illinois Insurance Code, take
16into account the effect of the management contract or service
17agreement on the continuation of benefits to enrollees and the
18financial condition of the health maintenance organization to
19be managed or serviced, and (ii) need not take into account the
20effect of the management contract or service agreement on
21competition.
22    (f) Except for small employer groups as defined in the
23Small Employer Rating, Renewability and Portability Health
24Insurance Act and except for medicare supplement policies as
25defined in Section 363 of the Illinois Insurance Code, a Health
26Maintenance Organization may by contract agree with a group or

 

 

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1other enrollment unit to effect refunds or charge additional
2premiums under the following terms and conditions:
3        (i) the amount of, and other terms and conditions with
4    respect to, the refund or additional premium are set forth
5    in the group or enrollment unit contract agreed in advance
6    of the period for which a refund is to be paid or
7    additional premium is to be charged (which period shall not
8    be less than one year); and
9        (ii) the amount of the refund or additional premium
10    shall not exceed 20% of the Health Maintenance
11    Organization's profitable or unprofitable experience with
12    respect to the group or other enrollment unit for the
13    period (and, for purposes of a refund or additional
14    premium, the profitable or unprofitable experience shall
15    be calculated taking into account a pro rata share of the
16    Health Maintenance Organization's administrative and
17    marketing expenses, but shall not include any refund to be
18    made or additional premium to be paid pursuant to this
19    subsection (f)). The Health Maintenance Organization and
20    the group or enrollment unit may agree that the profitable
21    or unprofitable experience may be calculated taking into
22    account the refund period and the immediately preceding 2
23    plan years.
24    The Health Maintenance Organization shall include a
25statement in the evidence of coverage issued to each enrollee
26describing the possibility of a refund or additional premium,

 

 

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1and upon request of any group or enrollment unit, provide to
2the group or enrollment unit a description of the method used
3to calculate (1) the Health Maintenance Organization's
4profitable experience with respect to the group or enrollment
5unit and the resulting refund to the group or enrollment unit
6or (2) the Health Maintenance Organization's unprofitable
7experience with respect to the group or enrollment unit and the
8resulting additional premium to be paid by the group or
9enrollment unit.
10    In no event shall the Illinois Health Maintenance
11Organization Guaranty Association be liable to pay any
12contractual obligation of an insolvent organization to pay any
13refund authorized under this Section.
14    (g) Rulemaking authority to implement Public Act 95-1045,
15if any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20(Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07;
2195-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09;
2295-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff.
231-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff.
246-1-10; 96-1000, eff. 7-2-10.)
 
25    Section 35. The Voluntary Health Services Plans Act is

 

 

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1amended by changing Section 10 as follows:
 
2    (215 ILCS 165/10)  (from Ch. 32, par. 604)
3    Sec. 10. Application of Insurance Code provisions. Health
4services plan corporations and all persons interested therein
5or dealing therewith shall be subject to the provisions of
6Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
7149, 155.37, 354, 355.2, 356g, 356g.5, 356g.5-1, 356r, 356t,
8356u, 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5,
9356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
10356z.14, 356z.15, 356z.18, 356z.19, 364.01, 367.2, 368a, 401,
11401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
12and (15) of Section 367 of the Illinois Insurance Code.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 95-189, eff. 8-16-07; 95-331, eff. 8-21-07;
2095-422, eff. 8-24-07; 95-520, eff. 8-28-07; 95-876, eff.
218-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; 95-1005,
22eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. 1-1-10;
2396-328, eff. 8-11-09; 96-833, eff. 6-1-10; 96-1000, eff.
247-2-10.)
 
25    Section 99. Effective date. This Act takes effect January

 

 

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11, 2012.