Rep. Elaine Nekritz

Filed: 4/13/2016

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 5576

2    AMENDMENT NO. ______. Amend House Bill 5576 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.4 as follows:
 
6    (215 ILCS 5/356z.4)
7    Sec. 356z.4. Coverage for contraceptives.
8    (a)(1) The General Assembly hereby finds and declares all
9of the following:
10        (A) Illinois has a long history of expanding timely
11    access to birth control to prevent unintended pregnancy.
12        (B) The federal Patient Protection and Affordable Care
13    Act includes a contraceptive coverage guarantee as part of
14    a broader requirement for health insurance to cover key
15    preventive care services without out-of-pocket costs for
16    patients.

 

 

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1        (C) The General Assembly intends to build on existing
2    State and federal law to promote gender equity and women's
3    health and to ensure greater contraceptive coverage equity
4    and timely access to all federal Food and Drug
5    Administration approved methods of birth control for all
6    individuals covered by an individual or group health
7    insurance policy in Illinois.
8        (D) Medical management techniques such as denials,
9    step therapy, or prior authorization in public and private
10    health care coverage can impede access to the most
11    effective contraceptive methods.
12    (2) As used in this subsection (a):
13    "Contraceptive services" includes consultations,
14examinations, procedures, and medical services related to the
15use of contraceptive methods (including natural family
16planning) to prevent an unintended pregnancy.
17    "Medical necessity", for the purposes of this subsection
18(a), includes, but is not limited to, considerations such as
19severity of side effects, differences in permanence and
20reversibility of contraceptive, and ability to adhere to the
21appropriate use of the item or service, as determined by the
22attending provider.
23    "Therapeutic equivalent version" means drugs, devices, or
24products that can be expected to have the same clinical effect
25and safety profile when administered to patients under the
26conditions specified in the labeling and satisfy the following

 

 

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1general criteria:
2        (i) they are approved as safe and effective;
3        (ii) they are pharmaceutical equivalents in that they
4    (A) contain identical amounts of the same active drug
5    ingredient in the same dosage form and route of
6    administration and (B) meet compendial or other applicable
7    standards of strength, quality, purity, and identity;
8        (iii) they are bioequivalent in that (A) they do not
9    present a known or potential bioequivalence problem and
10    they meet an acceptable in vitro standard or (B) if they do
11    present such a known or potential problem, they are shown
12    to meet an appropriate bioequivalence standard;
13        (iv) they are adequately labeled; and
14        (v) they are manufactured in compliance with Current
15    Good Manufacturing Practice regulations.
16    (3) An individual or group policy of accident and health
17insurance amended, delivered, issued, or renewed in this State
18after the effective date of this amendatory Act of the 99th
19General Assembly shall provide coverage for all of the
20following services and contraceptive methods:
21        (A) All contraceptive drugs, devices, and other
22    products approved by the United States Food and Drug
23    Administration. This includes all over-the-counter
24    contraceptive drugs, devices, and products approved by the
25    United States Food and Drug Administration, excluding male
26    condoms. The following apply:

 

 

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1            (i) If the United States Food and Drug
2        Administration has approved one or more therapeutic
3        equivalent versions of a contraceptive drug, device,
4        or product, a policy is not required to include all
5        such therapeutic equivalent versions in its formulary,
6        so long as at least one is included and covered without
7        cost-sharing and in accordance with this Section.
8            (ii) If an individual's attending provider
9        recommends a particular service or item approved by the
10        United States Food and Drug Administration based on a
11        determination of medical necessity with respect to
12        that individual, the plan or issuer must cover that
13        service or item without cost sharing. The plan or
14        issuer must defer to the determination of the attending
15        provider.
16            (iii) If a drug, device, or product is not covered,
17        plans and issuers must have an easily accessible,
18        transparent, and sufficiently expedient process that
19        is not unduly burdensome on the individual or a
20        provider or other individual acting as a patient's
21        authorized representative to ensure coverage without
22        cost sharing.
23            (iv) This coverage must provide for the dispensing
24        of 12 months' worth of contraception at one time.
25        (B) Voluntary sterilization procedures.
26        (C) Contraceptive services, patient education, and

 

 

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1    counseling on contraception.
2        (D) Follow-up services related to the drugs, devices,
3    products, and procedures covered under this Section,
4    including, but not limited to, management of side effects,
5    counseling for continued adherence, and device insertion
6    and removal.
7    (4) Except as otherwise provided in this subsection (a), a
8policy subject to this subsection (a) shall not impose a
9deductible, coinsurance, copayment, or any other cost-sharing
10requirement on the coverage provided.
11    (5) Except as otherwise authorized under this subsection
12(a), a policy shall not impose any restrictions or delays on
13the coverage required under this subsection (a).
14    (6) If, at any time, the Secretary of the United States
15Department of Health and Human Services, or its successor
16agency, promulgates rules or regulations to be published in the
17Federal Register or publishes a comment in the Federal Register
18or issues an opinion, guidance, or other action that would
19require the State, pursuant to any provision of the Patient
20Protection and Affordable Care Act (Public Law 111148),
21including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
22successor provision, to defray the cost of any coverage
23outlined in this subsection (a), then this subsection (a) is
24inoperative with respect to all coverage outlined in this
25subsection (a) other than that authorized under Section 1902 of
26the Social Security Act, 42 U.S.C. 1396a, and the State shall

 

 

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1not assume any obligation for the cost of the coverage set
2forth in this subsection (a).
3    (b) This subsection (b) shall become operative if and only
4if subsection (a) becomes inoperative.
5    (a) An individual or group policy of accident and health
6insurance amended, delivered, issued, or renewed in this State
7after the date this subsection (b) becomes operative effective
8date of this amendatory Act of the 93rd General Assembly that
9provides coverage for outpatient services and outpatient
10prescription drugs or devices must provide coverage for the
11insured and any dependent of the insured covered by the policy
12for all outpatient contraceptive services and all outpatient
13contraceptive drugs and devices approved by the Food and Drug
14Administration. Coverage required under this Section may not
15impose any deductible, coinsurance, waiting period, or other
16cost-sharing or limitation that is greater than that required
17for any outpatient service or outpatient prescription drug or
18device otherwise covered by the policy.
19    Nothing in this subsection (b) shall be construed to
20require an insurance company to cover services related to
21permanent sterilization that requires a surgical procedure.
22    (b) As used in this subsection (b) Section, "outpatient
23contraceptive service" means consultations, examinations,
24procedures, and medical services, provided on an outpatient
25basis and related to the use of contraceptive methods
26(including natural family planning) to prevent an unintended

 

 

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1pregnancy.
2    (c) Nothing in this Section shall be construed to require
3an insurance company to cover services related to an abortion
4as the term "abortion" is defined in the Illinois Abortion Law
5of 1975.
6    (d) Nothing in this Section shall be construed to require
7an insurance company to cover services related to permanent
8sterilization that requires a surgical procedure.
9(Source: P.A. 95-331, eff. 8-21-07.)".