State of Illinois
91st General Assembly
Legislation

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91_SB0388

 
                                               LRB9102390JSpc

 1        AN ACT concerning benefits for certain health treatments.

 2        WHEREAS, It is the intent  of  the  General  Assembly  to
 3    recognize that cancer clinical trials are designed to compare
 4    the  effectiveness  of  the standard medical treatment with a
 5    new  therapy  that  researchers  believe  will   prove   more
 6    effective,   based  on  scientific  evidence  and  that  such
 7    research provides the foundation for  improved  patient  care
 8    and decreased health care costs; and

 9        WHEREAS,  It  is  the  intent  of the General Assembly to
10    recognize that cancer clinical trials  involve  a  rigorously
11    developed  clinical  protocol  that includes goals, rationale
12    and background,  criteria  for  patient  selection,  specific
13    directions for administering therapy and monitoring patients,
14    definition of quantitative measures for determining treatment
15    response,  reporting  of results, and methods for documenting
16    and treating adverse reactions; and

17        WHEREAS, It is the intent  of  the  General  Assembly  to
18    recognize that virtually every major breakthrough for current
19    cancer  treatment  has  been  developed  through the clinical
20    trial system; and

21        WHEREAS, It is the intent  of  the  General  Assembly  to
22    acknowledge  that  cancer clinical trials can be cost neutral
23    in comparison to the standard therapy; therefore

24        Be it enacted by the People of  the  State  of  Illinois,
25    represented in the General Assembly:

26        Section  5.   The  Illinois  Insurance Code is amended by
27    adding Section 356y as follows:

28        (215 ILCS 5/356y new)
29        Sec.   356y.  Coverage   for    investigational    cancer
 
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 1    treatments.
 2        (a)  An individual or group policy of accident and health
 3    insurance  issued,  delivered,  amended,  or  renewed in this
 4    State after the effective date of this amendatory Act of  the
 5    91st  General Assembly must provide coverage for patient care
 6    of insureds, when medically appropriate, to participate in an
 7    approved research trial and shall provide  coverage  for  the
 8    patient  care  provided  pursuant  to  investigational cancer
 9    treatments as provided in subsection (b).
10        (b)  Coverage must be included for  an  item  or  service
11    that  would  otherwise be covered, subject to the limitations
12    and cost sharing  requirements  applicable  to  the  item  or
13    service,  when that item or service is provided to an insured
14    in the course of an investigational cancer treatment if:
15             (1)  the   treatment   is   a   qualifying    cancer
16        investigational treatment; and
17             (2)  the cancer treatment is administered as part of
18        the  medical  management  of  a life-threatening disease,
19        disorder, or health condition.
20        Coverage must be included for an  item  or  service  when
21    that  item  or  service  is  required to provide patient care
22    pursuant to the design of  a  research  trial,  except  those
23    items or services normally paid for by other funding sources,
24    such  as  the  costs  of  certain investigational agents, the
25    costs of any nonhealth services that might be required for  a
26    person to receive cancer treatment, and the costs of managing
27    the research; items or services subject to this exception may
28    be  covered  in addition to patient care at the discretion of
29    the health plan.
30        (c)  For  purposes  of  this  Section,  (A)   "qualifying
31    investigational  cancer  treatment" means a treatment (i) the
32    effectiveness of which has not been determined and (ii)  that
33    is under clinical investigation as part of an approved cancer
34    research  trial  in  Phase  II,  Phase  III,  or  Phase IV of
 
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 1    investigation and (B) "approved cancer research trial"  means
 2    (i) a cancer research trial approved by the U.S. Secretary of
 3    Health  and  Human  Services,  the  Director  of the National
 4    Institutes of Health, the Commissioner of the Food  and  Drug
 5    Administration (through an investigational new drug exemption
 6    under  Section  505(1) of the federal Food, Drug and Cosmetic
 7    Act or an  investigational  device  exemption  under  Section
 8    520(g)  of  that Act), the Secretary of Veterans Affairs, the
 9    Secretary of Defense, or a qualified  nongovernmental  cancer
10    research  entity  as  defined  in  guidelines of the National
11    Institutes of Health or (ii)  a  peer-reviewed  and  approved
12    cancer  research program, as defined by the U.S. Secretary of
13    Health and Human Services, conducted for the primary  purpose
14    of  determining  whether or not a cancer treatment is safe or
15    efficacious or has  any  other  characteristic  of  a  cancer
16    treatment  that  must be demonstrated in order for the cancer
17    treatment to be medically necessary or appropriate.
18        (d)  This Section is repealed on January 1, 2003.

19        Section 10.  The Health Maintenance Organization  Act  is
20    amended by changing Section 5-3 as follows:

21        (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
22        Sec. 5-3.  Insurance Code provisions.
23        (a)  Health Maintenance Organizations shall be subject to
24    the  provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
25    141.3, 143, 143c, 147, 148, 149, 151, 152, 153,  154,  154.5,
26    154.6,  154.7,  154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
27    356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
28    444, and 444.1, paragraph (c) of subsection  (2)  of  Section
29    367,  and  Articles  VIII  1/2, XII, XII 1/2, XIII, XIII 1/2,
30    XXV, and XXVI of the Illinois Insurance Code.
31        (b)  For purposes of the Illinois Insurance Code,  except
32    for  Sections  444  and 444.1 and Articles XIII and XIII 1/2,
 
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 1    Health Maintenance Organizations in the following  categories
 2    are deemed to be "domestic companies":
 3             (1)  a   corporation  authorized  under  the  Dental
 4        Service Plan Act or the Voluntary Health  Services  Plans
 5        Act;
 6             (2)  a  corporation organized under the laws of this
 7        State; or
 8             (3)  a  corporation  organized  under  the  laws  of
 9        another state, 30% or more of the enrollees of which  are
10        residents  of this State, except a corporation subject to
11        substantially the  same  requirements  in  its  state  of
12        organization  as  is  a  "domestic company" under Article
13        VIII 1/2 of the Illinois Insurance Code.
14        (c)  In considering the merger, consolidation,  or  other
15    acquisition  of  control of a Health Maintenance Organization
16    pursuant to Article VIII 1/2 of the Illinois Insurance Code,
17             (1)  the Director shall give  primary  consideration
18        to  the  continuation  of  benefits  to enrollees and the
19        financial conditions of the acquired  Health  Maintenance
20        Organization  after  the  merger, consolidation, or other
21        acquisition of control takes effect;
22             (2)(i)  the criteria specified in subsection  (1)(b)
23        of Section 131.8 of the Illinois Insurance Code shall not
24        apply  and (ii) the Director, in making his determination
25        with respect  to  the  merger,  consolidation,  or  other
26        acquisition  of  control,  need not take into account the
27        effect on competition of the  merger,  consolidation,  or
28        other acquisition of control;
29             (3)  the  Director  shall  have the power to require
30        the following information:
31                  (A)  certification by an independent actuary of
32             the  adequacy  of  the  reserves   of   the   Health
33             Maintenance Organization sought to be acquired;
34                  (B)  pro  forma financial statements reflecting
 
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 1             the combined balance sheets of the acquiring company
 2             and the Health Maintenance Organization sought to be
 3             acquired as of the end of the preceding year and  as
 4             of  a date 90 days prior to the acquisition, as well
 5             as  pro  forma   financial   statements   reflecting
 6             projected  combined  operation  for  a  period  of 2
 7             years;
 8                  (C)  a pro forma  business  plan  detailing  an
 9             acquiring   party's   plans   with  respect  to  the
10             operation of  the  Health  Maintenance  Organization
11             sought  to be acquired for a period of not less than
12             3 years; and
13                  (D)  such other  information  as  the  Director
14             shall require.
15        (d)  The  provisions  of Article VIII 1/2 of the Illinois
16    Insurance Code and this Section 5-3 shall apply to  the  sale
17    by any health maintenance organization of greater than 10% of
18    its  enrollee  population  (including  without limitation the
19    health maintenance organization's right, title, and  interest
20    in and to its health care certificates).
21        (e)  In  considering  any  management contract or service
22    agreement subject to Section 141.1 of the Illinois  Insurance
23    Code,  the  Director  (i)  shall, in addition to the criteria
24    specified in Section 141.2 of the  Illinois  Insurance  Code,
25    take  into  account  the effect of the management contract or
26    service  agreement  on  the  continuation  of   benefits   to
27    enrollees   and   the   financial  condition  of  the  health
28    maintenance organization to be managed or serviced, and  (ii)
29    need  not  take  into  account  the  effect of the management
30    contract or service agreement on competition.
31        (f)  Except for small employer groups as defined  in  the
32    Small  Employer  Rating,  Renewability and Portability Health
33    Insurance Act and except for medicare supplement policies  as
34    defined  in  Section  363  of  the Illinois Insurance Code, a
 
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 1    Health Maintenance Organization may by contract agree with  a
 2    group  or  other  enrollment unit to effect refunds or charge
 3    additional premiums under the following terms and conditions:
 4             (i)  the amount of, and other terms  and  conditions
 5        with respect to, the refund or additional premium are set
 6        forth  in the group or enrollment unit contract agreed in
 7        advance of the period for which a refund is to be paid or
 8        additional premium is to be charged (which  period  shall
 9        not be less than one year); and
10             (ii)  the amount of the refund or additional premium
11        shall   not   exceed   20%   of  the  Health  Maintenance
12        Organization's profitable or unprofitable experience with
13        respect to the group or other  enrollment  unit  for  the
14        period  (and,  for  purposes  of  a  refund or additional
15        premium, the profitable or unprofitable experience  shall
16        be calculated taking into account a pro rata share of the
17        Health   Maintenance  Organization's  administrative  and
18        marketing expenses, but shall not include any  refund  to
19        be made or additional premium to be paid pursuant to this
20        subsection (f)).  The Health Maintenance Organization and
21        the   group   or  enrollment  unit  may  agree  that  the
22        profitable or unprofitable experience may  be  calculated
23        taking into account the refund period and the immediately
24        preceding 2 plan years.
25        The  Health  Maintenance  Organization  shall  include  a
26    statement in the evidence of coverage issued to each enrollee
27    describing the possibility of a refund or additional premium,
28    and  upon request of any group or enrollment unit, provide to
29    the group or enrollment unit a description of the method used
30    to  calculate  (1)  the  Health  Maintenance   Organization's
31    profitable experience with respect to the group or enrollment
32    unit and the resulting refund to the group or enrollment unit
33    or  (2)  the  Health  Maintenance Organization's unprofitable
34    experience with respect to the group or enrollment  unit  and
 
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 1    the  resulting  additional premium to be paid by the group or
 2    enrollment unit.
 3        In  no  event  shall  the  Illinois  Health   Maintenance
 4    Organization  Guaranty  Association  be  liable  to  pay  any
 5    contractual  obligation  of  an insolvent organization to pay
 6    any refund authorized under this Section.
 7    (Source: P.A.  89-90,  eff.  6-30-95;  90-25,  eff.   1-1-98;
 8    90-177,  eff.  7-23-97;  90-372,  eff.  7-1-98;  90-583, eff.
 9    5-29-98; 90-655, eff. 7-30-98; 90-741, eff.  1-1-99;  revised
10    9-8-98.)

11        Section  15.   The Voluntary Health Services Plans Act is
12    amended by changing Section 10 as follows:

13        (215 ILCS 165/10) (from Ch. 32, par. 604)
14        Sec.  10.  Application  of  Insurance  Code   provisions.
15    Health  services plan corporations and all persons interested
16    therein  or  dealing  therewith  shall  be  subject  to   the
17    provisions  of  Article  XII  1/2 and Sections 3.1, 133, 140,
18    143, 143c, 149, 354, 355.2, 356r,  356t,  356u,  356v,  356w,
19    356x,  356y,  367.2,  401, 401.1, 402, 403, 403A, 408, 408.2,
20    and 412, and paragraphs (7) and (15) of Section  367  of  the
21    Illinois Insurance Code.
22    (Source: P.A.  89-514,  eff.  7-17-96;  90-7,  eff.  6-10-97;
23    90-25,  eff.  1-1-98;  90-655,  eff.  7-30-98;  90-741,  eff.
24    1-1-99.)

25        Section  99.   Effective  date.  This Act takes effect on
26    January 1, 2000.

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