101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB4312

 

Introduced 1/28/2020, by Rep. Avery Bourne

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356g  from Ch. 73, par. 968g

    Amends the Illinois Insurance Code. Makes a technical change in a Section concerning accident and health insurance coverage for mammograms and mastectomies.


LRB101 18661 BMS 68116 b

 

 

A BILL FOR

 

HB4312LRB101 18661 BMS 68116 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    Sec. 356g. Mammograms; mastectomies.
8    (a) Every insurer shall provide in each group or individual
9policy, contract, or certificate of insurance issued or renewed
10for persons who are residents of this State, coverage for
11screening by low-dose mammography for all women 35 years of age
12or older for the the presence of occult breast cancer within
13the provisions of the policy, contract, or certificate. The
14coverage shall be as follows:
15         (1) A baseline mammogram for women 35 to 39 years of
16    age.
17         (2) An annual mammogram for women 40 years of age or
18    older.
19         (3) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.

 

 

HB4312- 2 -LRB101 18661 BMS 68116 b

1        (4) For an individual or group policy of accident and
2    health insurance or a managed care plan that is amended,
3    delivered, issued, or renewed on or after the effective
4    date of this amendatory Act of the 101st General Assembly,
5    a comprehensive ultrasound screening and MRI of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue or when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10        (5) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13        (6) For an individual or group policy of accident and
14    health insurance or a managed care plan that is amended,
15    delivered, issued, or renewed on or after the effective
16    date of this amendatory Act of the 101st General Assembly,
17    a diagnostic mammogram when medically necessary, as
18    determined by a physician licensed to practice medicine in
19    all its branches, advanced practice registered nurse, or
20    physician assistant.
21    A policy subject to this subsection shall not impose a
22deductible, coinsurance, copayment, or any other cost-sharing
23requirement on the coverage provided; except that this sentence
24does not apply to coverage of diagnostic mammograms to the
25extent such coverage would disqualify a high-deductible health
26plan from eligibility for a health savings account pursuant to

 

 

HB4312- 3 -LRB101 18661 BMS 68116 b

1Section 223 of the Internal Revenue Code (26 U.S.C. 223).
2    For purposes of this Section:
3    "Diagnostic mammogram" means a mammogram obtained using
4diagnostic mammography.
5    "Diagnostic mammography" means a method of screening that
6is designed to evaluate an abnormality in a breast, including
7an abnormality seen or suspected on a screening mammogram or a
8subjective or objective abnormality otherwise detected in the
9breast.
10    "Low-dose mammography" means the x-ray examination of the
11breast using equipment dedicated specifically for mammography,
12including the x-ray tube, filter, compression device, and image
13receptor, with radiation exposure delivery of less than 1 rad
14per breast for 2 views of an average size breast. The term also
15includes digital mammography and includes breast
16tomosynthesis. As used in this Section, the term "breast
17tomosynthesis" means a radiologic procedure that involves the
18acquisition of projection images over the stationary breast to
19produce cross-sectional digital three-dimensional images of
20the breast.
21    If, at any time, the Secretary of the United States
22Department of Health and Human Services, or its successor
23agency, promulgates rules or regulations to be published in the
24Federal Register or publishes a comment in the Federal Register
25or issues an opinion, guidance, or other action that would
26require the State, pursuant to any provision of the Patient

 

 

HB4312- 4 -LRB101 18661 BMS 68116 b

1Protection and Affordable Care Act (Public Law 111-148),
2including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
3successor provision, to defray the cost of any coverage for
4breast tomosynthesis outlined in this subsection, then the
5requirement that an insurer cover breast tomosynthesis is
6inoperative other than any such coverage authorized under
7Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
8the State shall not assume any obligation for the cost of
9coverage for breast tomosynthesis set forth in this subsection.
10    (a-5) Coverage as described by subsection (a) shall be
11provided at no cost to the insured and shall not be applied to
12an annual or lifetime maximum benefit.
13    (a-10) When health care services are available through
14contracted providers and a person does not comply with plan
15provisions specific to the use of contracted providers, the
16requirements of subsection (a-5) are not applicable. When a
17person does not comply with plan provisions specific to the use
18of contracted providers, plan provisions specific to the use of
19non-contracted providers must be applied without distinction
20for coverage required by this Section and shall be at least as
21favorable as for other radiological examinations covered by the
22policy or contract.
23    (b) No policy of accident or health insurance that provides
24for the surgical procedure known as a mastectomy shall be
25issued, amended, delivered, or renewed in this State unless
26that coverage also provides for prosthetic devices or

 

 

HB4312- 5 -LRB101 18661 BMS 68116 b

1reconstructive surgery incident to the mastectomy. Coverage
2for breast reconstruction in connection with a mastectomy shall
3include:
4        (1) reconstruction of the breast upon which the
5    mastectomy has been performed;
6        (2) surgery and reconstruction of the other breast to
7    produce a symmetrical appearance; and
8        (3) prostheses and treatment for physical
9    complications at all stages of mastectomy, including
10    lymphedemas.
11Care shall be determined in consultation with the attending
12physician and the patient. The offered coverage for prosthetic
13devices and reconstructive surgery shall be subject to the
14deductible and coinsurance conditions applied to the
15mastectomy, and all other terms and conditions applicable to
16other benefits. When a mastectomy is performed and there is no
17evidence of malignancy then the offered coverage may be limited
18to the provision of prosthetic devices and reconstructive
19surgery to within 2 years after the date of the mastectomy. As
20used in this Section, "mastectomy" means the removal of all or
21part of the breast for medically necessary reasons, as
22determined by a licensed physician.
23    Written notice of the availability of coverage under this
24Section shall be delivered to the insured upon enrollment and
25annually thereafter. An insurer may not deny to an insured
26eligibility, or continued eligibility, to enroll or to renew

 

 

HB4312- 6 -LRB101 18661 BMS 68116 b

1coverage under the terms of the plan solely for the purpose of
2avoiding the requirements of this Section. An insurer may not
3penalize or reduce or limit the reimbursement of an attending
4provider or provide incentives (monetary or otherwise) to an
5attending provider to induce the provider to provide care to an
6insured in a manner inconsistent with this Section.
7    (c) Rulemaking authority to implement Public Act 95-1045,
8if any, is conditioned on the rules being adopted in accordance
9with all provisions of the Illinois Administrative Procedure
10Act and all rules and procedures of the Joint Committee on
11Administrative Rules; any purported rule not so adopted, for
12whatever reason, is unauthorized.
13(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)