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Public Act 097-0091 | ||||
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois, | ||||
represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by | ||||
changing Sections 356z.16 and 364.01 as follows:
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(215 ILCS 5/356z.16) | ||||
Sec. 356z.16. Applicability of mandated benefits to | ||||
supplemental policies. Unless specified otherwise, the | ||||
following Sections of the Illinois Insurance Code do not apply | ||||
to short-term travel, disability income, long-term care, | ||||
accident only, or limited or specified disease policies: 356b, | ||||
356c, 356d, 356g, 356k, 356m, 356n, 356p, 356q, 356r, 356t, | ||||
356u, 356w, 356x, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||
356z.8, 356z.12, 364.01, 367.2-5, and 367e.
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(Source: P.A. 96-180, eff. 1-1-10; 96-1000, eff. 7-2-10; | ||||
96-1034, eff. 1-1-11.)
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(215 ILCS 5/364.01) | ||||
Sec. 364.01. Qualified clinical cancer trials. | ||||
(a) No individual or group policy of accident and health | ||||
insurance issued or renewed in this State may be cancelled or | ||||
non-renewed for any individual based on that individual's | ||||
participation in a qualified clinical cancer trial. |
(b) Qualified clinical cancer trials must meet the | ||
following criteria: | ||
(1) the effectiveness of the treatment has not been | ||
determined relative to established therapies; | ||
(2) the trial is under clinical investigation as part | ||
of an approved cancer research trial in Phase II, Phase | ||
III, or Phase IV of investigation; | ||
(3) the trial is: | ||
(A) approved by the Food and Drug Administration; | ||
or | ||
(B) approved and funded by the National Institutes | ||
of Health, the Centers for Disease Control and | ||
Prevention, the Agency for Healthcare Research and | ||
Quality, the United States Department of Defense, the | ||
United States Department of Veterans Affairs, or the | ||
United States Department of Energy in the form of an | ||
investigational new drug application, or a cooperative | ||
group or center of any entity described in this | ||
subdivision (B); and
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(4) the patient's primary care physician, if any, is | ||
involved in the coordination of care.
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(c) No group policy of accident and health insurance shall | ||
exclude coverage for any routine patient care administered to | ||
an insured who is a qualified individual participating in a | ||
qualified clinical cancer trial, if the policy covers that same | ||
routine patient care of insureds not enrolled in a qualified |
clinical cancer trial. | ||
(d) The coverage that may not be excluded under subsection | ||
(c) of this Section is subject to all terms, conditions, | ||
restrictions, exclusions, and limitations that apply to the | ||
same routine patient care received by an insured not enrolled | ||
in a qualified clinical cancer trial, including the application | ||
of any authorization requirement, utilization review, or | ||
medical management practices. The insured or enrollee shall | ||
incur no greater out-of-pocket liability than had the insured | ||
or enrollee not enrolled in a qualified clinical cancer trial. | ||
(e) If the group policy of accident and health insurance | ||
uses a preferred provider program and a preferred provider | ||
provides routine patient care in connection with a qualified | ||
clinical cancer trial, then the insurer may require the insured | ||
to use the preferred provider if the preferred provider agrees | ||
to provide to the insured that routine patient care. | ||
(f) A qualified clinical cancer trial may not pay or refuse | ||
to pay for routine patient care of an individual participating | ||
in the trial, based in whole or in part on the person's having | ||
or not having coverage for routine patient care under a group | ||
policy of accident and health insurance. | ||
(g) Nothing in this Section shall be construed to limit an | ||
insurer's coverage with respect to clinical trials. | ||
(h) Nothing in this Section shall require coverage for | ||
out-of-network services where the underlying health benefit | ||
plan does not provide coverage for out-of-network services. |
(i) As used in this Section, "routine patient care" means | ||
all health care services provided in the qualified clinical | ||
cancer trial that are otherwise generally covered under the | ||
policy if those items or services were not provided in | ||
connection with a qualified clinical cancer trial consistent | ||
with the standard of care for the treatment of cancer, | ||
including the type and frequency of any diagnostic modality, | ||
that a provider typically provides to a cancer patient who is | ||
not enrolled in a qualified clinical cancer trial. "Routine | ||
patient care" does not include, and a group policy of accident | ||
and health insurance may exclude, coverage for: | ||
(1) a health care service, item, or drug that is the | ||
subject of the cancer clinical trial; | ||
(2) a health care service, item, or drug provided | ||
solely to satisfy data collection and analysis needs for | ||
the qualified clinical cancer trial that is not used in the | ||
direct clinical management of the patient; | ||
(3) an investigational drug or device that has not been | ||
approved for market by the United States Food and Drug | ||
Administration; | ||
(4) transportation, lodging, food, or other expenses | ||
for the patient or a family member or companion of the | ||
patient that are associated with the travel to or from a | ||
facility providing the qualified clinical cancer trial, | ||
unless the policy covers these expenses for a cancer | ||
patient who is not enrolled in a qualified clinical cancer |
trial; | ||
(5) a health care service, item, or drug customarily | ||
provided by the qualified clinical cancer trial sponsors | ||
free of charge for any patient; | ||
(6) a health care service or item, which except for the | ||
fact that it is being provided in a qualified clinical | ||
cancer trial, is otherwise specifically excluded from | ||
coverage under the insured's policy, including: | ||
(A) costs of extra treatments, services, | ||
procedures, tests, or drugs that would not be performed | ||
or administered except for the fact that the insured is | ||
participating in the cancer clinical trial; and | ||
(B) costs of nonhealth care services that the | ||
patient is required to receive as a result of | ||
participation in the approved cancer clinical trial; | ||
(7) costs for services, items, or drugs that are | ||
eligible for reimbursement from a source other than a | ||
patient's contract or policy providing for third-party | ||
payment or prepayment of health or medical expenses, | ||
including the sponsor of the approved cancer clinical | ||
trial; or | ||
(8) costs associated with approved cancer clinical | ||
trials designed exclusively to test toxicity or disease | ||
pathophysiology, unless the policy covers these expenses | ||
for a cancer patient who is not enrolled in a qualified | ||
clinical cancer trial; or |
(9) a health care service or item that is eligible for | ||
reimbursement by a source other than the insured's policy, | ||
including the sponsor of the qualified clinical cancer | ||
trial. | ||
The definitions of the terms "health care services", | ||
"Non-Preferred Provider", "Preferred Provider", and "Preferred | ||
Provider Program", stated in 50 IL Adm. Code Part 2051 | ||
Preferred Provider Programs apply to these terms in this | ||
Section. | ||
(j) The external review procedures established under the | ||
Health Carrier External Review Act shall apply to the | ||
provisions under this Section. | ||
(Source: P.A. 93-1000, eff. 1-1-05.)
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Section 99. Effective date. This Act takes effect January | ||
1, 2012.
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