Bill Text: IL HB5399 | 2021-2022 | 102nd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with intensity modulated radiation therapy for the same indication if specified conditions are satisfied. Provides standards concerning the aggregate amount chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy. Provides that proton therapy coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract. Defines terms. Effective January 1, 2023.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2022-02-18 - Rule 19(a) / Re-referred to Rules Committee [HB5399 Detail]

Download: Illinois-2021-HB5399-Introduced.html

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102ND GENERAL ASSEMBLY State of Illinois 2021 and 2022 HB5399 Introduced , by Rep. Norine K. Hammond SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.53 new
Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance that is amended, delivered, issued, or renewed on or after January 1, 2024 shall cover a medically necessary hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with a standard radiation therapy protocol delivered with intensity modulated radiation therapy for the same indication if specified conditions are satisfied. Provides standards concerning the aggregate amount chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy. Provides that proton therapy coverage may not impose an annual deductible, coinsurance, or other cost-sharing limitation that is greater than that required for radiation therapy and other similar benefits within the insurance policy or contract. Defines terms. Effective January 1, 2023.
LRB102 25959 BMS 35349 b
A BILL FOR
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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
adding Section 356z.53 as follows:
(215 ILCS 5/356z.53 new)
Sec. 356z.53. Proton therapy access.
(a) As used in this Section:
"Aggregate amount" means the total amount paid under an
individual or group policy of accident and health insurance
for the applicable radiation treatment delivery current
procedural terminology codes to deliver a biological effective
dose.
"Biological effective dose" means the total prescribed
radiation dose delivered in a course of radiation therapy
treatments to induce tumor cell death.
"Current procedural terminology code" means the unique
numerical designations established by the American Medical
Association for various medical, surgical, and diagnostic
services used in billing health care services.
"Eligible patient" means a cancer patient who is approved
for a standard radiation therapy protocol delivered with IMRT
and prescribed a hypofractionated proton therapy protocol for

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the treatment of the same cancer.
"Hypofractionated proton therapy protocol" means a cancer
treatment protocol that involves the delivery of fewer, larger
radiation therapy treatment doses than a standard radiation
therapy protocol to deliver a biological effective dose.
"Intensity modulated radiation therapy" or "IMRT" means a
type of conformal radiation therapy that delivers x-ray
radiation beams of different intensities from many angles for
the treatment of tumors.
"Proton therapy" means the advanced form of radiation
therapy that utilizes protons as the radiation delivery method
for the treatment of tumors.
"Radiation therapy" means the delivery of a biological
effective dose with proton therapy, IMRT, brachytherapy,
stereotactic body radiation therapy, three-dimensional
conformal radiation therapy, or other forms of therapy using
radiation.
"Registry" means an organized system that uses
observational study methods to collect uniform clinical data
to evaluate specified outcomes for a population defined by a
particular disease and is compliant with the principles
established by the Registries for Evaluating Patient Outcomes:
A User's Guide - Third Edition published by the Agency for
Healthcare Research and Quality of the U.S. Department of
Health and Human Services.
"Standard radiation therapy protocol" means a cancer

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treatment protocol that involves the delivery of radiation
therapy treatment doses over an extended period of time to
deliver a biological effective dose.
"Treatment dose" means the amount of radiation delivered
in a single treatment or fraction of radiation therapy.
(b) An individual or group policy of accident and health
insurance that is amended, delivered, issued, or renewed on or
after January 1, 2024 shall cover a medically necessary
hypofractionated proton therapy protocol to deliver a
biological effective dose by paying the same aggregate amount
as would be paid for the delivery of the same biological
effective dose with a standard radiation therapy protocol
delivered with IMRT for the same indication if the following
conditions are satisfied:
(1) coverage is provided to an eligible patient who is
being treated as part of a clinical trial or registry;
(2) the eligible patient is diagnosed with a cancer
type or indication that can be treated with a
hypofractionated proton therapy protocol; and
(3) the radiation oncologist prescribing the
hypofractionated proton therapy protocol is board
certified or board eligible in the specialty of radiation
oncology.
(c) If coverage of a hypofractionated proton therapy
protocol is required pursuant to subsection (b), then:
(1) the aggregate amount must be equal to the average

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cost actually paid by an individual or group policy of
accident and health insurance for a standard radiation
therapy protocol delivered with IMRT required to deliver
the prescribed biological effective dose for the
particular indication. For the purposes of this paragraph
(1), aggregate amounts must be established by reference to
the amount paid for a course of IMRT treatment under a
standard radiation therapy protocol delivered with IMRT
for the indication under the applicable policy; and
(2) coverage may not impose an annual deductible,
coinsurance, or other cost-sharing limitation that is
greater than that required for radiation therapy and other
similar benefits within the insurance policy or contract.
(d) Notwithstanding any other provision of this Section to
the contrary, the aggregate amount:
(1) reimbursed for the hypofractionated proton therapy
protocol must not exceed the average aggregate amount paid
by an individual or group policy of accident and health
insurance for a course of IMRT treatment under a standard
radiation therapy protocol delivered with IMRT to deliver
the prescribed biological effective dose for the same
indication;
(2) chargeable to or payable by an eligible patient
for a covered course of hypofractionated proton therapy by
an in-network provider must not exceed the aggregate
amount that would otherwise be chargeable to or payable by

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the eligible patient for a course of IMRT treatment under
a standard radiation therapy protocol delivered with IMRT
that is covered by the applicable policy for the delivery
of the same biological effective dose by an in-network
provider; and
(3) chargeable to or payable by an eligible patient
for a covered course of hypofractionated proton therapy by
an out-of-network provider must not exceed the aggregate
amount that would otherwise be chargeable to or payable by
the eligible patient for a course of treatment under a
standard radiation therapy protocol delivered with IMRT
that is covered by the applicable policy for the delivery
of the same biological effective dose by an out-of-network
provider. However, the patient is not responsible for
amounts greater than the allowable maximum charge.
Section 99. Effective date. This Act takes effect January
1, 2023.