Bill Text: IL HB5576 | 2015-2016 | 99th General Assembly | Chaptered

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Bill Title: Amends the Illinois Insurance Code. Makes changes to a Section concerning coverage for contraceptives. Provides that an individual or group health policy shall provide coverage for all contraceptive drugs, devices, and other products approved by the United States Food and Drug Administration, including over-the-counter contraceptive drugs, devices, and products; voluntary sterilization procedures; contraceptive services, patient education, and counseling on contraception; and follow-up services related to their use. Provides that if the United States Food and Drug Administration has approved one or more therapeutic equivalent versions of a contraceptive drug, device, or product, a policy is not required to include all therapeutic equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing; if an individual's attending provider recommends a particular service or item approved by the United States Food and Drug Administration based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing and the plan or issuer must defer to the determination of the attending provider; if a drug, device or product is not covered, plans and issuers must have an easily accessible, transparent, and sufficiently expedient process that is not unduly burdensome on the individual or a provider or person acting as a patient's authorized representative to ensure coverage without cost sharing; and that coverage must provide for the dispensing of 12 months' worth of contraception at one time. Defines "contraceptive services", "medical necessity", and "therapeutic equivalent version". Removes language prohibiting the provisions from being construed to require an insurance company cover services related to permanent sterilization requiring a surgical procedure.

Spectrum: Partisan Bill (Democrat 49-0)

Status: (Passed) 2016-07-29 - Public Act . . . . . . . . . 99-0672 [HB5576 Detail]

Download: Illinois-2015-HB5576-Chaptered.html

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Public Act 099-0672
HB5576 Enrolled LRB099 20488 EGJ 45009 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 356z.4 as follows:
(215 ILCS 5/356z.4)
Sec. 356z.4. Coverage for contraceptives.
(a)(1) The General Assembly hereby finds and declares all
of the following:
(A) Illinois has a long history of expanding timely
access to birth control to prevent unintended pregnancy.
(B) The federal Patient Protection and Affordable Care
Act includes a contraceptive coverage guarantee as part of
a broader requirement for health insurance to cover key
preventive care services without out-of-pocket costs for
patients.
(C) The General Assembly intends to build on existing
State and federal law to promote gender equity and women's
health and to ensure greater contraceptive coverage equity
and timely access to all federal Food and Drug
Administration approved methods of birth control for all
individuals covered by an individual or group health
insurance policy in Illinois.

(D) Medical management techniques such as denials,
step therapy, or prior authorization in public and private
health care coverage can impede access to the most
effective contraceptive methods.
(2) As used in this subsection (a):
"Contraceptive services" includes consultations,
examinations, procedures, and medical services related to the
use of contraceptive methods (including natural family
planning) to prevent an unintended pregnancy.
"Medical necessity", for the purposes of this subsection
(a), includes, but is not limited to, considerations such as
severity of side effects, differences in permanence and
reversibility of contraceptive, and ability to adhere to the
appropriate use of the item or service, as determined by the
attending provider.
"Therapeutic equivalent version" means drugs, devices, or
products that can be expected to have the same clinical effect
and safety profile when administered to patients under the
conditions specified in the labeling and satisfy the following
general criteria:
(i) they are approved as safe and effective;
(ii) they are pharmaceutical equivalents in that they
(A) contain identical amounts of the same active drug
ingredient in the same dosage form and route of
administration and (B) meet compendial or other applicable
standards of strength, quality, purity, and identity;

(iii) they are bioequivalent in that (A) they do not
present a known or potential bioequivalence problem and
they meet an acceptable in vitro standard or (B) if they do
present such a known or potential problem, they are shown
to meet an appropriate bioequivalence standard;
(iv) they are adequately labeled; and
(v) they are manufactured in compliance with Current
Good Manufacturing Practice regulations.
(3) An individual or group policy of accident and health
insurance amended, delivered, issued, or renewed in this State
after the effective date of this amendatory Act of the 99th
General Assembly shall provide coverage for all of the
following services and contraceptive methods:
(A) All contraceptive drugs, devices, and other
products approved by the United States Food and Drug
Administration. This includes all over-the-counter
contraceptive drugs, devices, and products approved by the
United States Food and Drug Administration, excluding male
condoms. The following apply:
(i) If the United States Food and Drug
Administration has approved one or more therapeutic
equivalent versions of a contraceptive drug, device,
or product, a policy is not required to include all
such therapeutic equivalent versions in its formulary,
so long as at least one is included and covered without
cost-sharing and in accordance with this Section.

(ii) If an individual's attending provider
recommends a particular service or item approved by the
United States Food and Drug Administration based on a
determination of medical necessity with respect to
that individual, the plan or issuer must cover that
service or item without cost sharing. The plan or
issuer must defer to the determination of the attending
provider.
(iii) If a drug, device, or product is not covered,
plans and issuers must have an easily accessible,
transparent, and sufficiently expedient process that
is not unduly burdensome on the individual or a
provider or other individual acting as a patient's
authorized representative to ensure coverage without
cost sharing.
(iv) This coverage must provide for the dispensing
of 12 months' worth of contraception at one time.
(B) Voluntary sterilization procedures.
(C) Contraceptive services, patient education, and
counseling on contraception.
(D) Follow-up services related to the drugs, devices,
products, and procedures covered under this Section,
including, but not limited to, management of side effects,
counseling for continued adherence, and device insertion
and removal.
(4) Except as otherwise provided in this subsection (a), a

policy subject to this subsection (a) shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided.
(5) Except as otherwise authorized under this subsection
(a), a policy shall not impose any restrictions or delays on
the coverage required under this subsection (a).
(6) If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in the
Federal Register or publishes a comment in the Federal Register
or issues an opinion, guidance, or other action that would
require the State, pursuant to any provision of the Patient
Protection and Affordable Care Act (Public Law 111–148),
including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
successor provision, to defray the cost of any coverage
outlined in this subsection (a), then this subsection (a) is
inoperative with respect to all coverage outlined in this
subsection (a) other than that authorized under Section 1902 of
the Social Security Act, 42 U.S.C. 1396a, and the State shall
not assume any obligation for the cost of the coverage set
forth in this subsection (a).
(b) This subsection (b) shall become operative if and only
if subsection (a) becomes inoperative.
(a) An individual or group policy of accident and health
insurance amended, delivered, issued, or renewed in this State
after the date this subsection (b) becomes operative effective

date of this amendatory Act of the 93rd General Assembly that
provides coverage for outpatient services and outpatient
prescription drugs or devices must provide coverage for the
insured and any dependent of the insured covered by the policy
for all outpatient contraceptive services and all outpatient
contraceptive drugs and devices approved by the Food and Drug
Administration. Coverage required under this Section may not
impose any deductible, coinsurance, waiting period, or other
cost-sharing or limitation that is greater than that required
for any outpatient service or outpatient prescription drug or
device otherwise covered by the policy.
Nothing in this subsection (b) shall be construed to
require an insurance company to cover services related to
permanent sterilization that requires a surgical procedure.
(b) As used in this subsection (b) Section, "outpatient
contraceptive service" means consultations, examinations,
procedures, and medical services, provided on an outpatient
basis and related to the use of contraceptive methods
(including natural family planning) to prevent an unintended
pregnancy.
(c) Nothing in this Section shall be construed to require
an insurance company to cover services related to an abortion
as the term "abortion" is defined in the Illinois Abortion Law
of 1975.
(d) If a plan or issuer utilizes a network of providers,
nothing in this Section shall be construed to require coverage

or to prohibit the plan or issuer from imposing cost-sharing
for items or services described in this Section that are
provided or delivered by an out-of-network provider, unless the
plan or issuer does not have in its network a provider who is
able to or is willing to provide the applicable items or
services.
(d) Nothing in this Section shall be construed to require
an insurance company to cover services related to permanent
sterilization that requires a surgical procedure.
(Source: P.A. 95-331, eff. 8-21-07.)