94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
SB0012


 
Introduced 1/26/2005, by Sen. Mattie Hunter - James A. DeLeo
 
SYNOPSIS AS INTRODUCED:
 		
















215 ILCS 5/356g
  from Ch. 73, par. 968g


215 ILCS 125/4-6.1
  from Ch. 111 1/2, par. 1408.7







    Amends the Illinois Insurance Code and the Health Maintenance Organization Act.  Requires coverage of mammograms for women under 40 years of age with a family history of breast cancer or other risk factors at the age and intervals deemed medically necessary by the woman's health care provider. Effective immediately.
















LRB094 04124 LJB 34145 b

















 


 


A BILL FOR









 











SB0012

LRB094 04124 LJB 34145 b






1
    AN ACT concerning  insurance.

 
2
    Be it enacted by the People of the State of Illinois,
 
3
represented in the General Assembly:


 
4
    Section 5. The Illinois Insurance Code is amended  by 
5
changing 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

9
policy, contract, or certificate of insurance issued or renewed 
10
for persons
who are residents of this State, coverage for 
11
screening by low-dose
mammography for all women 35 years of age 
12
or older for the presence of
occult breast cancer within the 
13
provisions of the policy, contract, or
certificate. The 
14
coverage 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 or other risk factors.

23
    These benefits shall be at least as favorable as for other 
24
radiological
examinations and subject to the same dollar 
25
limits, deductibles, and
co-insurance factors. For purposes of 
26
this Section, "low-dose mammography"
means the x-ray 
27
examination of the breast using equipment dedicated

28
specifically for mammography, including the x-ray tube, 
29
filter, compression
device, and image receptor, with radiation 
30
exposure delivery of less than
1 rad per breast for 2 views of 
31
an average size breast.

32
    (b) No policy of accident or health insurance that provides 
 


 






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1
for
the surgical procedure known as a mastectomy shall be 
2
issued, amended,
delivered, or renewed in this State unless

3
that coverage also provides for prosthetic devices
or 
4
reconstructive surgery
incident to the mastectomy.
Coverage 
5
for breast reconstruction in connection with a mastectomy shall

6
include:


7
        (1) reconstruction of the breast upon which the 
8
    mastectomy has been
performed;


9
        (2) surgery and reconstruction of the other breast to 
10
    produce a
symmetrical appearance; and


11
        (3) prostheses and treatment for physical 
12
    complications at all stages of
mastectomy, including 
13
    lymphedemas.

14
Care shall be determined in consultation with the attending 
15
physician and the
patient.
The offered coverage for prosthetic 
16
devices and
reconstructive surgery shall be subject to the 
17
deductible and coinsurance
conditions applied to the 
18
mastectomy, and all other terms and conditions
applicable to 
19
other benefits.  When a mastectomy is performed and there is
no 
20
evidence of malignancy then the offered coverage may be limited 
21
to the
provision of prosthetic devices and reconstructive 
22
surgery to within 2
years after the date of the mastectomy. As 
23
used in this Section,
"mastectomy" means the removal of all or 
24
part of the breast for medically
necessary reasons, as 
25
determined by a licensed physician.

26
    Written notice of the availability of coverage under this 
27
Section shall be
delivered to the insured upon enrollment and 
28
annually thereafter.  An insurer
may not deny to an insured 
29
eligibility, or continued eligibility, to enroll or
to renew 
30
coverage under the terms of the plan solely for the purpose of

31
avoiding the requirements of this Section.  An insurer may not 
32
penalize or
reduce or
limit the reimbursement of an attending 
33
provider or provide incentives
(monetary or otherwise) to an 
34
attending provider to induce the provider to
provide care to an 
35
insured in a manner inconsistent with this Section.

36
(Source: P.A. 92-48, eff. 7-3-01.)

 
 


 






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1
    Section 10. The Health Maintenance Organization Act is 
2
amended  by changing Section 4-6.1 as follows:
 



3
    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)



4
    Sec. 4-6.1. Mammograms; mastectomies. 

5
    (a) Every contract or evidence of coverage
issued by a 
6
Health Maintenance Organization for persons who are residents 
7
of
this State shall contain coverage for screening by low-dose 
8
mammography
for all women 35 years of age or older for the 
9
presence of occult breast
cancer.  The coverage shall be as 
10
follows:


11
        (1) A baseline mammogram for women 35 to 39 years of 
12
    age.


13
        (2) An annual mammogram for women 40 years of age or 
14
    older.

15
        (3) A mammogram at the age and intervals considered 
16
    medically necessary by the woman's health care provider for 
17
    women under 40 years of age and having a family history of 
18
    breast cancer or other risk factors.
19
    These benefits shall be at least as favorable as for other 
20
radiological
examinations and subject to the same dollar 
21
limits, deductibles, and
co-insurance factors.  For purposes of 
22
this Section, "low-dose mammography"
means the x-ray 
23
examination of the breast using equipment dedicated

24
specifically for mammography, including the x-ray tube, 
25
filter, compression
device, and image receptor, with radiation 
26
exposure delivery of less than 1
rad per breast for 2 views of 
27
an average size breast.

28
    (b) No contract or evidence of coverage issued by a health 
29
maintenance
organization that provides for the
surgical 
30
procedure known as a mastectomy shall be issued, amended, 
31
delivered,
or renewed in this State on or after the effective 
32
date of this amendatory Act
of the 92nd General Assembly unless 
33
that coverage also provides for prosthetic
devices or 
34
reconstructive surgery incident to the mastectomy, providing 
 


 






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1
that
the mastectomy is performed after the effective date of 
2
this amendatory Act.
Coverage for breast reconstruction in 
3
connection
with a mastectomy shall
include:


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.

11
Care shall be determined in consultation with the attending 
12
physician and the
patient.
The offered coverage for prosthetic 
13
devices and
reconstructive surgery shall be subject to the 
14
deductible and coinsurance
conditions applied to the 
15
mastectomy and all other terms and conditions
applicable to 
16
other benefits.  When a mastectomy is performed and there is
no 
17
evidence of malignancy, then the offered coverage may be 
18
limited to the
provision of prosthetic devices and 
19
reconstructive surgery to within 2
years after the date of the 
20
mastectomy. As used in this Section,
"mastectomy" means the 
21
removal of all or part of the breast for medically
necessary 
22
reasons, as determined by a licensed physician.

23
    Written notice of the availability of coverage under this 
24
Section shall be
delivered to the enrollee upon enrollment and 
25
annually thereafter.  A
health maintenance organization may not 
26
deny to an enrollee eligibility, or
continued eligibility, to 
27
enroll or
to renew coverage under the terms of the plan solely 
28
for the purpose of
avoiding the requirements of this Section.  A 
29
health maintenance organization
may not penalize or
reduce or

30
limit the reimbursement of an attending provider or provide 
31
incentives
(monetary or otherwise) to an attending provider to 
32
induce the provider to
provide care to an insured in a manner 
33
inconsistent with this Section.

34
(Source: P.A. 92-48, eff. 7-3-01.)

 

35
    Section 99. Effective date. This Act takes effect upon 
 


 






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becoming law.