[ Search ] [ Legislation ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ Engrossed ] | [ Enrolled ] |
| [ Senate Amendment 001 ] | [ Senate Amendment 003 ] |
91_HB1622sam002
LRB9104751JSgcam01
1 AMENDMENT TO HOUSE BILL 1622
2 AMENDMENT NO. . Amend House Bill 1622, AS AMENDED,
3 by replacing everything after the enacting clause with the
4 following:
5 "Section 5. The Civil Administrative Code of Illinois is
6 amended by adding Section 56.3 as follows:
7 (20 ILCS 1405/56.3 new)
8 Sec. 56.3. Investigational cancer treatments; study.
9 (a) The Department of Insurance shall conduct an
10 analysis and study of costs and benefits derived from the
11 implementation of the coverage requirements for
12 investigational cancer treatments established under Section
13 356y of the Illinois Insurance Code. The study shall cover
14 the years 2000, 2001, and 2002. The study shall include an
15 analysis of the effect of the coverage requirements on the
16 cost of insurance and health care, the results of the
17 treatments to patients, the mortality rate among cancer
18 patients, any improvements in care of patients, and any
19 improvements in the quality of life of patients.
20 (b) The Department shall report the results of its study
21 to the General Assembly and the Governor on or before March
22 1, 2003.
-2- LRB9104751JSgcam01
1 Section 10. The Illinois Insurance Code is amended by
2 adding Section 356y as follows:
3 (215 ILCS 5/356y new)
4 Sec. 356y. Coverage for investigational cancer
5 treatments.
6 (a) An individual or group policy of accident and health
7 insurance issued, delivered, amended, or renewed in this
8 State more than 120 days after the effective date of this
9 amendatory Act of the 91st General Assembly must offer
10 coverage for routine patient care of insureds, when medically
11 appropriate and the insured has a terminal condition related
12 to cancer that according to the diagnosis of the treating
13 physician, licensed to practice medicine in all its branches,
14 is considered life threatening, to participate in an approved
15 cancer research trial and shall provide coverage for the
16 patient care provided pursuant to investigational cancer
17 treatments as provided in subsection (b). Coverage under
18 this Section may have an annual benefit limit of $10,000.
19 (b) Coverage shall include routine patient care costs
20 such as blood tests, x-rays, bone scans, magnetic resonance
21 images, patient visits, hospital stays, or other similar
22 costs generally incurred by the insured party in standard
23 cancer treatment. Routine patient care costs specifically
24 shall not include the cost of any clinical trial therapies,
25 regimens, or combinations thereof, any drugs or
26 pharmaceuticals in connection with an approved clinical
27 trial, any costs associated with the provision of any goods,
28 services, or benefits that are generally furnished without
29 charge in connection with an approved clinical trial program
30 for treatment of cancer, any additional costs associated with
31 the provision of any goods, services, or benefits that
32 previously have been provided to, paid for, or reimbursed, or
33 any other similar costs. Routine patient care costs shall
-3- LRB9104751JSgcam01
1 specifically not include costs for treatments or services
2 prescribed for the convenience of the insured, enrollee, or
3 physician. It is specifically the intent of this Section not
4 to relieve the sponsor or a clinical trial program of
5 financial responsibility for accepted costs of the program.
6 (c) For purposes of this Section, coverage is provided
7 only for cancer trials that meet each of the following
8 criteria:
9 (1) the effectiveness of the treatment has not been
10 determined relative to established therapies;
11 (2) the trial is under clinical investigation as
12 part of an approved cancer research trial in Phase II,
13 Phase III, or Phase IV of investigation;
14 (3) the trial is approved by the U.S. Secretary of
15 Health and Human Services, the Director of the National
16 Institutes of Health, the Commissioner of the Food and
17 Drug Administration (through an investigational new drug
18 exemption under Section 505(l) of the federal Food, Drug,
19 and Cosmetic Act or an investigational device exemption
20 under Section 520(g) of that Act), or a qualified
21 nongovernmental cancer research entity as defined in
22 guidelines of the National Institutes of Health or a peer
23 reviewed and approved cancer research program, as defined
24 by the U.S. Secretary of Health and Human Services,
25 conducted for the primary purpose of determining whether
26 or not a cancer treatment is safe or efficacious or has
27 any other characteristic of a cancer treatment that must
28 be demonstrated in order for the cancer treatment to be
29 medically necessary or appropriate;
30 (4) the trial is being conducted at multiple sites
31 throughout the State;
32 (5) the patient's primary care physician, if any,
33 is involved in the coordination of care; and
34 (6) the results of the investigational trial will
-4- LRB9104751JSgcam01
1 be submitted for publication in peer-reviewed scientific
2 studies, research, or literature published in or accepted
3 for publication by medical journals that meet nationally
4 recognized requirements for scientific manuscripts and
5 that submit most of their published articles for review
6 by experts who are not part of the editorial staff.
7 These studies may include those conducted by or under the
8 auspices of the federal government's Agency for Health
9 Care Policy and Research, National Institutes of Health,
10 National Cancer Institute, National Academy of Sciences,
11 Health Care Financing Administration, and any national
12 board recognized by the National Institutes of Health for
13 the purpose of evaluating the medical value of health
14 services.
15 (d) This Section is repealed on January 1, 2003.
16 Section 15. The Health Maintenance Organization Act is
17 amended by changing Section 5-3 as follows:
18 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
19 Sec. 5-3. Insurance Code provisions.
20 (a) Health Maintenance Organizations shall be subject to
21 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
22 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
23 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356v, 356w, 356x,
24 356y, 367i, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
25 444, and 444.1, paragraph (c) of subsection (2) of Section
26 367, and Articles VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
27 XXV, and XXVI of the Illinois Insurance Code.
28 (b) For purposes of the Illinois Insurance Code, except
29 for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
30 Health Maintenance Organizations in the following categories
31 are deemed to be "domestic companies":
32 (1) a corporation authorized under the Dental
-5- LRB9104751JSgcam01
1 Service Plan Act or the Voluntary Health Services Plans
2 Act;
3 (2) a corporation organized under the laws of this
4 State; or
5 (3) a corporation organized under the laws of
6 another state, 30% or more of the enrollees of which are
7 residents of this State, except a corporation subject to
8 substantially the same requirements in its state of
9 organization as is a "domestic company" under Article
10 VIII 1/2 of the Illinois Insurance Code.
11 (c) In considering the merger, consolidation, or other
12 acquisition of control of a Health Maintenance Organization
13 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
14 (1) the Director shall give primary consideration
15 to the continuation of benefits to enrollees and the
16 financial conditions of the acquired Health Maintenance
17 Organization after the merger, consolidation, or other
18 acquisition of control takes effect;
19 (2)(i) the criteria specified in subsection (1)(b)
20 of Section 131.8 of the Illinois Insurance Code shall not
21 apply and (ii) the Director, in making his determination
22 with respect to the merger, consolidation, or other
23 acquisition of control, need not take into account the
24 effect on competition of the merger, consolidation, or
25 other acquisition of control;
26 (3) the Director shall have the power to require
27 the following information:
28 (A) certification by an independent actuary of
29 the adequacy of the reserves of the Health
30 Maintenance Organization sought to be acquired;
31 (B) pro forma financial statements reflecting
32 the combined balance sheets of the acquiring company
33 and the Health Maintenance Organization sought to be
34 acquired as of the end of the preceding year and as
-6- LRB9104751JSgcam01
1 of a date 90 days prior to the acquisition, as well
2 as pro forma financial statements reflecting
3 projected combined operation for a period of 2
4 years;
5 (C) a pro forma business plan detailing an
6 acquiring party's plans with respect to the
7 operation of the Health Maintenance Organization
8 sought to be acquired for a period of not less than
9 3 years; and
10 (D) such other information as the Director
11 shall require.
12 (d) The provisions of Article VIII 1/2 of the Illinois
13 Insurance Code and this Section 5-3 shall apply to the sale
14 by any health maintenance organization of greater than 10% of
15 its enrollee population (including without limitation the
16 health maintenance organization's right, title, and interest
17 in and to its health care certificates).
18 (e) In considering any management contract or service
19 agreement subject to Section 141.1 of the Illinois Insurance
20 Code, the Director (i) shall, in addition to the criteria
21 specified in Section 141.2 of the Illinois Insurance Code,
22 take into account the effect of the management contract or
23 service agreement on the continuation of benefits to
24 enrollees and the financial condition of the health
25 maintenance organization to be managed or serviced, and (ii)
26 need not take into account the effect of the management
27 contract or service agreement on competition.
28 (f) Except for small employer groups as defined in the
29 Small Employer Rating, Renewability and Portability Health
30 Insurance Act and except for medicare supplement policies as
31 defined in Section 363 of the Illinois Insurance Code, a
32 Health Maintenance Organization may by contract agree with a
33 group or other enrollment unit to effect refunds or charge
34 additional premiums under the following terms and conditions:
-7- LRB9104751JSgcam01
1 (i) the amount of, and other terms and conditions
2 with respect to, the refund or additional premium are set
3 forth in the group or enrollment unit contract agreed in
4 advance of the period for which a refund is to be paid or
5 additional premium is to be charged (which period shall
6 not be less than one year); and
7 (ii) the amount of the refund or additional premium
8 shall not exceed 20% of the Health Maintenance
9 Organization's profitable or unprofitable experience with
10 respect to the group or other enrollment unit for the
11 period (and, for purposes of a refund or additional
12 premium, the profitable or unprofitable experience shall
13 be calculated taking into account a pro rata share of the
14 Health Maintenance Organization's administrative and
15 marketing expenses, but shall not include any refund to
16 be made or additional premium to be paid pursuant to this
17 subsection (f)). The Health Maintenance Organization and
18 the group or enrollment unit may agree that the
19 profitable or unprofitable experience may be calculated
20 taking into account the refund period and the immediately
21 preceding 2 plan years.
22 The Health Maintenance Organization shall include a
23 statement in the evidence of coverage issued to each enrollee
24 describing the possibility of a refund or additional premium,
25 and upon request of any group or enrollment unit, provide to
26 the group or enrollment unit a description of the method used
27 to calculate (1) the Health Maintenance Organization's
28 profitable experience with respect to the group or enrollment
29 unit and the resulting refund to the group or enrollment unit
30 or (2) the Health Maintenance Organization's unprofitable
31 experience with respect to the group or enrollment unit and
32 the resulting additional premium to be paid by the group or
33 enrollment unit.
34 In no event shall the Illinois Health Maintenance
-8- LRB9104751JSgcam01
1 Organization Guaranty Association be liable to pay any
2 contractual obligation of an insolvent organization to pay
3 any refund authorized under this Section.
4 (Source: P.A. 89-90, eff. 6-30-95; 90-25, eff. 1-1-98;
5 90-177, eff. 7-23-97; 90-372, eff. 7-1-98; 90-583, eff.
6 5-29-98; 90-655, eff. 7-30-98; 90-741, eff. 1-1-99; revised
7 9-8-98.)
8 Section 20. The Voluntary Health Services Plans Act is
9 amended by changing Section 10 as follows:
10 (215 ILCS 165/10) (from Ch. 32, par. 604)
11 Sec. 10. Application of Insurance Code provisions.
12 Health services plan corporations and all persons interested
13 therein or dealing therewith shall be subject to the
14 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
15 143, 143c, 149, 354, 355.2, 356r, 356t, 356u, 356v, 356w,
16 356x, 356y, 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2,
17 and 412, and paragraphs (7) and (15) of Section 367 of the
18 Illinois Insurance Code.
19 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
20 90-25, eff. 1-1-98; 90-655, eff. 7-30-98; 90-741, eff.
21 1-1-99.)
22 Section 99. Effective date. This Act takes effect on
23 January 1, 2000.".