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1 | AN ACT concerning health, which may be referred to as the | ||||||||||||||||||||||||
2 | Reducing Breast Cancer Disparities Act.
| ||||||||||||||||||||||||
3 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||
4 | represented in the General Assembly:
| ||||||||||||||||||||||||
5 | Article 1. Legislative Intent | ||||||||||||||||||||||||
6 | Section 1-1. Legislative intent. The General Assembly | ||||||||||||||||||||||||
7 | finds that the mortality associated with breast cancer for | ||||||||||||||||||||||||
8 | minority women in Illinois is significantly higher compared to | ||||||||||||||||||||||||
9 | non-minority women. This disparity has grown over the last 2 | ||||||||||||||||||||||||
10 | decades and is unacceptable. A recent New England Journal of | ||||||||||||||||||||||||
11 | Medicine article found that even modest cost-sharing deters | ||||||||||||||||||||||||
12 | women from getting a mammogram. The reduction was most | ||||||||||||||||||||||||
13 | pronounced for those with lower income and less education. Many | ||||||||||||||||||||||||
14 | other studies have found that women with lower family income | ||||||||||||||||||||||||
15 | and those relying on public programs for healthcare access | ||||||||||||||||||||||||
16 | mammography at a lower rate. It is, therefore, the intent of | ||||||||||||||||||||||||
17 | this legislation to decrease health disparities as they relate | ||||||||||||||||||||||||
18 | to breast cancer and to improve access for all women to quality | ||||||||||||||||||||||||
19 | breast cancer screening and treatment where necessary. | ||||||||||||||||||||||||
20 | Article 5. Improving State Healthcare Programs | ||||||||||||||||||||||||
21 | With Respect To | ||||||||||||||||||||||||
22 | Mammography And Breast Cancer Treatment |
| |||||||
| |||||||
1 | Section 5-5. The Illinois Public Aid Code is amended by | ||||||
2 | changing Section 5-5 as follows: | ||||||
3 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
4 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
5 | rule, shall
determine the quantity and quality of and the rate | ||||||
6 | of reimbursement for the
medical assistance for which
payment | ||||||
7 | will be authorized, and the medical services to be provided,
| ||||||
8 | which may include all or part of the following: (1) inpatient | ||||||
9 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
10 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
11 | services; (5) physicians'
services whether furnished in the | ||||||
12 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
13 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
14 | care furnished by licensed practitioners; (7)
home health care | ||||||
15 | services; (8) private duty nursing service; (9) clinic
| ||||||
16 | services; (10) dental services, including prevention and | ||||||
17 | treatment of periodontal disease and dental caries disease for | ||||||
18 | pregnant women; (11) physical therapy and related
services; | ||||||
19 | (12) prescribed drugs, dentures, and prosthetic devices; and
| ||||||
20 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
21 | the eye,
or by an optometrist, whichever the person may select; | ||||||
22 | (13) other
diagnostic, screening, preventive, and | ||||||
23 | rehabilitative services; (14)
transportation and such other | ||||||
24 | expenses as may be necessary; (15) medical
treatment of sexual |
| |||||||
| |||||||
1 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
2 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
3 | sustained as a result of the sexual assault, including
| ||||||
4 | examinations and laboratory tests to discover evidence which | ||||||
5 | may be used in
criminal proceedings arising from the sexual | ||||||
6 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
7 | anemia; and (17)
any other medical care, and any other type of | ||||||
8 | remedial care recognized
under the laws of this State, but not | ||||||
9 | including abortions, or induced
miscarriages or premature | ||||||
10 | births, unless, in the opinion of a physician,
such procedures | ||||||
11 | are necessary for the preservation of the life of the
woman | ||||||
12 | seeking such treatment, or except an induced premature birth
| ||||||
13 | intended to produce a live viable child and such procedure is | ||||||
14 | necessary
for the health of the mother or her unborn child. The | ||||||
15 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
16 | providing medical assistance
to anyone eligible therefor under | ||||||
17 | this Code where such physician has been
found guilty of | ||||||
18 | performing an abortion procedure in a wilful and wanton
manner | ||||||
19 | upon a woman who was not pregnant at the time such abortion
| ||||||
20 | procedure was performed. The term "any other type of remedial | ||||||
21 | care" shall
include nursing care and nursing home service for | ||||||
22 | persons who rely on
treatment by spiritual means alone through | ||||||
23 | prayer for healing.
| ||||||
24 | Notwithstanding any other provision of this Section, a | ||||||
25 | comprehensive
tobacco use cessation program that includes | ||||||
26 | purchasing prescription drugs or
prescription medical devices |
| |||||||
| |||||||
1 | approved by the Food and Drug administration shall
be covered | ||||||
2 | under the medical assistance
program under this Article for | ||||||
3 | persons who are otherwise eligible for
assistance under this | ||||||
4 | Article.
| ||||||
5 | Notwithstanding any other provision of this Code, the | ||||||
6 | Illinois
Department may not require, as a condition of payment | ||||||
7 | for any laboratory
test authorized under this Article, that a | ||||||
8 | physician's handwritten signature
appear on the laboratory | ||||||
9 | test order form. The Illinois Department may,
however, impose | ||||||
10 | other appropriate requirements regarding laboratory test
order | ||||||
11 | documentation.
| ||||||
12 | The Department of Healthcare and Family Services shall | ||||||
13 | provide the following services to
persons
eligible for | ||||||
14 | assistance under this Article who are participating in
| ||||||
15 | education, training or employment programs operated by the | ||||||
16 | Department of Human
Services as successor to the Department of | ||||||
17 | Public Aid:
| ||||||
18 | (1) dental services, which shall include but not be | ||||||
19 | limited to
prosthodontics; and
| ||||||
20 | (2) eyeglasses prescribed by a physician skilled in the | ||||||
21 | diseases of the
eye, or by an optometrist, whichever the | ||||||
22 | person may select.
| ||||||
23 | The Illinois Department, by rule, may distinguish and | ||||||
24 | classify the
medical services to be provided only in accordance | ||||||
25 | with the classes of
persons designated in Section 5-2.
| ||||||
26 | The Department of Healthcare and Family Services must |
| |||||||
| |||||||
1 | provide coverage and reimbursement for amino acid-based | ||||||
2 | elemental formulas, regardless of delivery method, for the | ||||||
3 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
4 | short bowel syndrome when the prescribing physician has issued | ||||||
5 | a written order stating that the amino acid-based elemental | ||||||
6 | formula is medically necessary.
| ||||||
7 | The Illinois Department shall authorize the provision of, | ||||||
8 | and shall
authorize payment for, screening by low-dose | ||||||
9 | mammography for the presence of
occult breast cancer for women | ||||||
10 | 35 years of age or older who are eligible
for medical | ||||||
11 | assistance under this Article, as follows: a baseline
mammogram | ||||||
12 | for women 35 to 39 years of age and an
annual mammogram for | ||||||
13 | women 40 years of age or older. All screenings
shall
include a | ||||||
14 | physical breast exam, instruction on self-examination and
| ||||||
15 | information regarding the frequency of self-examination and | ||||||
16 | its value as a
preventative tool. For purposes of As used in | ||||||
17 | this Section, "low-dose mammography" means
the x-ray | ||||||
18 | examination of the breast using equipment dedicated | ||||||
19 | specifically
for mammography, including the x-ray tube, | ||||||
20 | filter, compression device,
screens, image receptors receptor , | ||||||
21 | and cassettes, with an average radiation exposure delivery
of | ||||||
22 | less than one rad mid-breast, with 2 views for each breast. The | ||||||
23 | term also includes digital mammography.
| ||||||
24 | On and after July 1, 2008, screening and diagnostic | ||||||
25 | mammography shall be reimbursed at the same rate as the | ||||||
26 | Medicare program's rates, including the increased |
| |||||||
| |||||||
1 | reimbursement for digital mammography. | ||||||
2 | The Department shall convene an expert panel including | ||||||
3 | representatives of hospitals, free-standing mammography | ||||||
4 | facilities, and doctors, including radiologists, to establish | ||||||
5 | quality standards. Based on these quality standards, the | ||||||
6 | Department shall provide for bonus payments to mammography | ||||||
7 | facilities meeting the standards for screening and diagnosis. | ||||||
8 | The bonus payments shall be at least 15% higher than the | ||||||
9 | Medicare rates for mammography. | ||||||
10 | Subject to federal approval, the Department shall | ||||||
11 | establish a rate methodology for mammography at federally | ||||||
12 | qualified health centers and other encounter-rate clinics. | ||||||
13 | These clinics or centers may also collaborate with other | ||||||
14 | hospital-based mammography facilities. | ||||||
15 | The Department shall establish a methodology to remind | ||||||
16 | women who are age-appropriate for screening mammography, but | ||||||
17 | who have not received a mammogram within the previous 18 | ||||||
18 | months, of the importance and benefit of screening mammography. | ||||||
19 | The Department shall establish a performance goal for | ||||||
20 | primary care providers with respect to their female patients | ||||||
21 | over age 40 receiving an annual mammogram. This performance | ||||||
22 | goal shall be used to provide additional reimbursement in the | ||||||
23 | form of a quality performance bonus to primary care providers | ||||||
24 | who meet that goal. | ||||||
25 | The Department shall devise a means of case-managing or | ||||||
26 | patient navigation for beneficiaries diagnosed with breast |
| |||||||
| |||||||
1 | cancer. This program shall initially operate as a pilot program | ||||||
2 | in areas of the State with the highest incidence of mortality | ||||||
3 | related to breast cancer. At least one pilot program site shall | ||||||
4 | be in the metropolitan Chicago area and at least one site shall | ||||||
5 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
6 | pilot program shall be carried out measuring health outcomes | ||||||
7 | and cost of care for those served by the pilot program compared | ||||||
8 | to similarly situated patients who are not served by the pilot | ||||||
9 | program. | ||||||
10 | Any medical or health care provider shall immediately | ||||||
11 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
12 | services and is suspected
of drug abuse or is addicted as | ||||||
13 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
14 | Act, referral to a local substance abuse treatment provider
| ||||||
15 | licensed by the Department of Human Services or to a licensed
| ||||||
16 | hospital which provides substance abuse treatment services. | ||||||
17 | The Department of Healthcare and Family Services
shall assure | ||||||
18 | coverage for the cost of treatment of the drug abuse or
| ||||||
19 | addiction for pregnant recipients in accordance with the | ||||||
20 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
21 | Human Services.
| ||||||
22 | All medical providers providing medical assistance to | ||||||
23 | pregnant women
under this Code shall receive information from | ||||||
24 | the Department on the
availability of services under the Drug | ||||||
25 | Free Families with a Future or any
comparable program providing | ||||||
26 | case management services for addicted women,
including |
| |||||||
| |||||||
1 | information on appropriate referrals for other social services
| ||||||
2 | that may be needed by addicted women in addition to treatment | ||||||
3 | for addiction.
| ||||||
4 | The Illinois Department, in cooperation with the | ||||||
5 | Departments of Human
Services (as successor to the Department | ||||||
6 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
7 | public awareness campaign, may
provide information concerning | ||||||
8 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
9 | health care, and other pertinent programs directed at
reducing | ||||||
10 | the number of drug-affected infants born to recipients of | ||||||
11 | medical
assistance.
| ||||||
12 | Neither the Department of Healthcare and Family Services | ||||||
13 | nor the Department of Human
Services shall sanction the | ||||||
14 | recipient solely on the basis of
her substance abuse.
| ||||||
15 | The Illinois Department shall establish such regulations | ||||||
16 | governing
the dispensing of health services under this Article | ||||||
17 | as it shall deem
appropriate. The Department
should
seek the | ||||||
18 | advice of formal professional advisory committees appointed by
| ||||||
19 | the Director of the Illinois Department for the purpose of | ||||||
20 | providing regular
advice on policy and administrative matters, | ||||||
21 | information dissemination and
educational activities for | ||||||
22 | medical and health care providers, and
consistency in | ||||||
23 | procedures to the Illinois Department.
| ||||||
24 | The Illinois Department may develop and contract with | ||||||
25 | Partnerships of
medical providers to arrange medical services | ||||||
26 | for persons eligible under
Section 5-2 of this Code. |
| |||||||
| |||||||
1 | Implementation of this Section may be by
demonstration projects | ||||||
2 | in certain geographic areas. The Partnership shall
be | ||||||
3 | represented by a sponsor organization. The Department, by rule, | ||||||
4 | shall
develop qualifications for sponsors of Partnerships. | ||||||
5 | Nothing in this
Section shall be construed to require that the | ||||||
6 | sponsor organization be a
medical organization.
| ||||||
7 | The sponsor must negotiate formal written contracts with | ||||||
8 | medical
providers for physician services, inpatient and | ||||||
9 | outpatient hospital care,
home health services, treatment for | ||||||
10 | alcoholism and substance abuse, and
other services determined | ||||||
11 | necessary by the Illinois Department by rule for
delivery by | ||||||
12 | Partnerships. Physician services must include prenatal and
| ||||||
13 | obstetrical care. The Illinois Department shall reimburse | ||||||
14 | medical services
delivered by Partnership providers to clients | ||||||
15 | in target areas according to
provisions of this Article and the | ||||||
16 | Illinois Health Finance Reform Act,
except that:
| ||||||
17 | (1) Physicians participating in a Partnership and | ||||||
18 | providing certain
services, which shall be determined by | ||||||
19 | the Illinois Department, to persons
in areas covered by the | ||||||
20 | Partnership may receive an additional surcharge
for such | ||||||
21 | services.
| ||||||
22 | (2) The Department may elect to consider and negotiate | ||||||
23 | financial
incentives to encourage the development of | ||||||
24 | Partnerships and the efficient
delivery of medical care.
| ||||||
25 | (3) Persons receiving medical services through | ||||||
26 | Partnerships may receive
medical and case management |
| |||||||
| |||||||
1 | services above the level usually offered
through the | ||||||
2 | medical assistance program.
| ||||||
3 | Medical providers shall be required to meet certain | ||||||
4 | qualifications to
participate in Partnerships to ensure the | ||||||
5 | delivery of high quality medical
services. These | ||||||
6 | qualifications shall be determined by rule of the Illinois
| ||||||
7 | Department and may be higher than qualifications for | ||||||
8 | participation in the
medical assistance program. Partnership | ||||||
9 | sponsors may prescribe reasonable
additional qualifications | ||||||
10 | for participation by medical providers, only with
the prior | ||||||
11 | written approval of the Illinois Department.
| ||||||
12 | Nothing in this Section shall limit the free choice of | ||||||
13 | practitioners,
hospitals, and other providers of medical | ||||||
14 | services by clients.
In order to ensure patient freedom of | ||||||
15 | choice, the Illinois Department shall
immediately promulgate | ||||||
16 | all rules and take all other necessary actions so that
provided | ||||||
17 | services may be accessed from therapeutically certified | ||||||
18 | optometrists
to the full extent of the Illinois Optometric | ||||||
19 | Practice Act of 1987 without
discriminating between service | ||||||
20 | providers.
| ||||||
21 | The Department shall apply for a waiver from the United | ||||||
22 | States Health
Care Financing Administration to allow for the | ||||||
23 | implementation of
Partnerships under this Section.
| ||||||
24 | The Illinois Department shall require health care | ||||||
25 | providers to maintain
records that document the medical care | ||||||
26 | and services provided to recipients
of Medical Assistance under |
| |||||||
| |||||||
1 | this Article. The Illinois Department shall
require health care | ||||||
2 | providers to make available, when authorized by the
patient, in | ||||||
3 | writing, the medical records in a timely fashion to other
| ||||||
4 | health care providers who are treating or serving persons | ||||||
5 | eligible for
Medical Assistance under this Article. All | ||||||
6 | dispensers of medical services
shall be required to maintain | ||||||
7 | and retain business and professional records
sufficient to | ||||||
8 | fully and accurately document the nature, scope, details and
| ||||||
9 | receipt of the health care provided to persons eligible for | ||||||
10 | medical
assistance under this Code, in accordance with | ||||||
11 | regulations promulgated by
the Illinois Department. The rules | ||||||
12 | and regulations shall require that proof
of the receipt of | ||||||
13 | prescription drugs, dentures, prosthetic devices and
| ||||||
14 | eyeglasses by eligible persons under this Section accompany | ||||||
15 | each claim
for reimbursement submitted by the dispenser of such | ||||||
16 | medical services.
No such claims for reimbursement shall be | ||||||
17 | approved for payment by the Illinois
Department without such | ||||||
18 | proof of receipt, unless the Illinois Department
shall have put | ||||||
19 | into effect and shall be operating a system of post-payment
| ||||||
20 | audit and review which shall, on a sampling basis, be deemed | ||||||
21 | adequate by
the Illinois Department to assure that such drugs, | ||||||
22 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
23 | is being made are actually being
received by eligible | ||||||
24 | recipients. Within 90 days after the effective date of
this | ||||||
25 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
26 | a
current list of acquisition costs for all prosthetic devices |
| |||||||
| |||||||
1 | and any
other items recognized as medical equipment and | ||||||
2 | supplies reimbursable under
this Article and shall update such | ||||||
3 | list on a quarterly basis, except that
the acquisition costs of | ||||||
4 | all prescription drugs shall be updated no
less frequently than | ||||||
5 | every 30 days as required by Section 5-5.12.
| ||||||
6 | The rules and regulations of the Illinois Department shall | ||||||
7 | require
that a written statement including the required opinion | ||||||
8 | of a physician
shall accompany any claim for reimbursement for | ||||||
9 | abortions, or induced
miscarriages or premature births. This | ||||||
10 | statement shall indicate what
procedures were used in providing | ||||||
11 | such medical services.
| ||||||
12 | The Illinois Department shall require all dispensers of | ||||||
13 | medical
services, other than an individual practitioner or | ||||||
14 | group of practitioners,
desiring to participate in the Medical | ||||||
15 | Assistance program
established under this Article to disclose | ||||||
16 | all financial, beneficial,
ownership, equity, surety or other | ||||||
17 | interests in any and all firms,
corporations, partnerships, | ||||||
18 | associations, business enterprises, joint
ventures, agencies, | ||||||
19 | institutions or other legal entities providing any
form of | ||||||
20 | health care services in this State under this Article.
| ||||||
21 | The Illinois Department may require that all dispensers of | ||||||
22 | medical
services desiring to participate in the medical | ||||||
23 | assistance program
established under this Article disclose, | ||||||
24 | under such terms and conditions as
the Illinois Department may | ||||||
25 | by rule establish, all inquiries from clients
and attorneys | ||||||
26 | regarding medical bills paid by the Illinois Department, which
|
| |||||||
| |||||||
1 | inquiries could indicate potential existence of claims or liens | ||||||
2 | for the
Illinois Department.
| ||||||
3 | Enrollment of a vendor that provides non-emergency medical | ||||||
4 | transportation,
defined by the Department by rule,
shall be
| ||||||
5 | conditional for 180 days. During that time, the Department of | ||||||
6 | Healthcare and Family Services may
terminate the vendor's | ||||||
7 | eligibility to participate in the medical assistance
program | ||||||
8 | without cause. That termination of eligibility is not subject | ||||||
9 | to the
Department's hearing process.
| ||||||
10 | The Illinois Department shall establish policies, | ||||||
11 | procedures,
standards and criteria by rule for the acquisition, | ||||||
12 | repair and replacement
of orthotic and prosthetic devices and | ||||||
13 | durable medical equipment. Such
rules shall provide, but not be | ||||||
14 | limited to, the following services: (1)
immediate repair or | ||||||
15 | replacement of such devices by recipients without
medical | ||||||
16 | authorization; and (2) rental, lease, purchase or | ||||||
17 | lease-purchase of
durable medical equipment in a | ||||||
18 | cost-effective manner, taking into
consideration the | ||||||
19 | recipient's medical prognosis, the extent of the
recipient's | ||||||
20 | needs, and the requirements and costs for maintaining such
| ||||||
21 | equipment. Such rules shall enable a recipient to temporarily | ||||||
22 | acquire and
use alternative or substitute devices or equipment | ||||||
23 | pending repairs or
replacements of any device or equipment | ||||||
24 | previously authorized for such
recipient by the Department.
| ||||||
25 | The Department shall execute, relative to the nursing home | ||||||
26 | prescreening
project, written inter-agency agreements with the |
| |||||||
| |||||||
1 | Department of Human
Services and the Department on Aging, to | ||||||
2 | effect the following: (i) intake
procedures and common | ||||||
3 | eligibility criteria for those persons who are receiving
| ||||||
4 | non-institutional services; and (ii) the establishment and | ||||||
5 | development of
non-institutional services in areas of the State | ||||||
6 | where they are not currently
available or are undeveloped.
| ||||||
7 | The Illinois Department shall develop and operate, in | ||||||
8 | cooperation
with other State Departments and agencies and in | ||||||
9 | compliance with
applicable federal laws and regulations, | ||||||
10 | appropriate and effective
systems of health care evaluation and | ||||||
11 | programs for monitoring of
utilization of health care services | ||||||
12 | and facilities, as it affects
persons eligible for medical | ||||||
13 | assistance under this Code.
| ||||||
14 | The Illinois Department shall report annually to the | ||||||
15 | General Assembly,
no later than the second Friday in April of | ||||||
16 | 1979 and each year
thereafter, in regard to:
| ||||||
17 | (a) actual statistics and trends in utilization of | ||||||
18 | medical services by
public aid recipients;
| ||||||
19 | (b) actual statistics and trends in the provision of | ||||||
20 | the various medical
services by medical vendors;
| ||||||
21 | (c) current rate structures and proposed changes in | ||||||
22 | those rate structures
for the various medical vendors; and
| ||||||
23 | (d) efforts at utilization review and control by the | ||||||
24 | Illinois Department.
| ||||||
25 | The period covered by each report shall be the 3 years | ||||||
26 | ending on the June
30 prior to the report. The report shall |
| |||||||
| |||||||
1 | include suggested legislation
for consideration by the General | ||||||
2 | Assembly. The filing of one copy of the
report with the | ||||||
3 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
4 | the Clerk of the House of Representatives, one copy with the | ||||||
5 | President,
one copy with the Minority Leader and one copy with | ||||||
6 | the Secretary of the
Senate, one copy with the Legislative | ||||||
7 | Research Unit, and such additional
copies
with the State | ||||||
8 | Government Report Distribution Center for the General
Assembly | ||||||
9 | as is required under paragraph (t) of Section 7 of the State
| ||||||
10 | Library Act shall be deemed sufficient to comply with this | ||||||
11 | Section.
| ||||||
12 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
| ||||||
13 | Section 5-10. The Counties Code is amended by changing | ||||||
14 | Section 5-1069 as follows:
| ||||||
15 | (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
| ||||||
16 | Sec. 5-1069. Group life, health, accident, hospital, and | ||||||
17 | medical
insurance.
| ||||||
18 | (a) The county board of any county may arrange to provide, | ||||||
19 | for
the benefit of employees of the county, group life, health, | ||||||
20 | accident, hospital,
and medical insurance, or any one or any | ||||||
21 | combination of those types of
insurance, or the county board | ||||||
22 | may self-insure, for the benefit of its
employees, all or a | ||||||
23 | portion of the employees' group life, health, accident,
| ||||||
24 | hospital, and medical insurance, or any one or any combination |
| |||||||
| |||||||
1 | of those
types of insurance, including a combination of | ||||||
2 | self-insurance and other
types of insurance authorized by this | ||||||
3 | Section, provided that the county
board complies with all other | ||||||
4 | requirements of this Section. The insurance
may include | ||||||
5 | provision for employees who rely on treatment by prayer or
| ||||||
6 | spiritual means alone for healing in accordance with the tenets | ||||||
7 | and
practice of a well recognized religious denomination. The | ||||||
8 | county board may
provide for payment by the county of a portion | ||||||
9 | or all of the premium or
charge for the insurance with the | ||||||
10 | employee paying the balance of the
premium or charge, if any. | ||||||
11 | If the county board undertakes a plan under
which the county | ||||||
12 | pays only a portion of the premium or charge, the county
board | ||||||
13 | shall provide for withholding and deducting from the | ||||||
14 | compensation of
those employees who consent to join the plan | ||||||
15 | the balance of the premium or
charge for the insurance.
| ||||||
16 | (b) If the county board does not provide for self-insurance | ||||||
17 | or for a plan
under which the county pays a portion or all of | ||||||
18 | the premium or charge for a
group insurance plan, the county | ||||||
19 | board may provide for withholding and
deducting from the | ||||||
20 | compensation of those employees who consent thereto the
total | ||||||
21 | premium or charge for any group life, health, accident, | ||||||
22 | hospital, and
medical insurance.
| ||||||
23 | (c) The county board may exercise the powers granted in | ||||||
24 | this Section only if
it provides for self-insurance or, where | ||||||
25 | it makes arrangements to provide
group insurance through an | ||||||
26 | insurance carrier, if the kinds of group
insurance are obtained |
| |||||||
| |||||||
1 | from an insurance company authorized to do business
in the | ||||||
2 | State of Illinois. The county board may enact an ordinance
| ||||||
3 | prescribing the method of operation of the insurance program.
| ||||||
4 | (d) If a county, including a home rule county, is a | ||||||
5 | self-insurer for
purposes of providing health insurance | ||||||
6 | coverage for its employees, the
insurance coverage shall | ||||||
7 | include screening by low-dose mammography for all
women 35 | ||||||
8 | years of age or older for the presence of occult breast cancer
| ||||||
9 | unless the county elects to provide mammograms itself under | ||||||
10 | Section
5-1069.1. The coverage shall be as 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 | Those benefits shall be at least as favorable as for other | ||||||
16 | radiological
examinations and subject to the same dollar | ||||||
17 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
18 | this subsection, "low-dose mammography"
means the x-ray | ||||||
19 | examination of the breast using equipment dedicated
| ||||||
20 | specifically for mammography, including the x-ray tube, | ||||||
21 | filter, compression
device, screens, and image receptors, and | ||||||
22 | cassettes, with an average radiation exposure
delivery of less | ||||||
23 | than one rad mid-breast, with 2 views for each breast. The term | ||||||
24 | also includes digital mammography. The
requirement that | ||||||
25 | mammograms be included in health insurance coverage as
provided | ||||||
26 | in this subsection (d) is an exclusive power and function of |
| |||||||
| |||||||
1 | the
State and is a denial and limitation under Article VII, | ||||||
2 | Section 6,
subsection (h) of the Illinois Constitution of home | ||||||
3 | rule county powers. A
home rule county to which this subsection | ||||||
4 | applies must comply with every
provision of this subsection.
| ||||||
5 | (e) The term "employees" as used in this Section includes | ||||||
6 | elected or
appointed officials but does not include temporary | ||||||
7 | employees.
| ||||||
8 | (f) The county board may, by ordinance, arrange to provide | ||||||
9 | group life,
health, accident, hospital, and medical insurance, | ||||||
10 | or any one or a combination
of those types of insurance, under | ||||||
11 | this Section to retired former employees and
retired former | ||||||
12 | elected or appointed officials of the county.
| ||||||
13 | (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
| ||||||
14 | Section 5-15. The Illinois Municipal Code is amended by | ||||||
15 | changing Section 10-4-2 as follows:
| ||||||
16 | (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
| ||||||
17 | Sec. 10-4-2. Group insurance.
| ||||||
18 | (a) The corporate authorities of any municipality may | ||||||
19 | arrange
to provide, for the benefit of employees of the | ||||||
20 | municipality, group life,
health, accident, hospital, and | ||||||
21 | medical insurance, or any one or any
combination of those types | ||||||
22 | of insurance, and may arrange to provide that
insurance for the | ||||||
23 | benefit of the spouses or dependents of those employees.
The | ||||||
24 | insurance may include provision for employees or other insured |
| |||||||
| |||||||
1 | persons
who rely on treatment by prayer or spiritual means | ||||||
2 | alone for healing in
accordance with the tenets and practice of | ||||||
3 | a well recognized religious
denomination. The corporate | ||||||
4 | authorities may provide for payment by the
municipality of a | ||||||
5 | portion of the premium or charge for the insurance with
the | ||||||
6 | employee paying the balance of the premium or charge. If the | ||||||
7 | corporate
authorities undertake a plan under which the | ||||||
8 | municipality pays a portion of
the premium or charge, the | ||||||
9 | corporate authorities shall provide for
withholding and | ||||||
10 | deducting from the compensation of those municipal
employees | ||||||
11 | who consent to join the plan the balance of the premium or | ||||||
12 | charge
for the insurance.
| ||||||
13 | (b) If the corporate authorities do not provide for a plan | ||||||
14 | under which
the municipality pays a portion of the premium or | ||||||
15 | charge for a group
insurance plan, the corporate authorities | ||||||
16 | may provide for withholding
and deducting from the compensation | ||||||
17 | of those employees who consent thereto
the premium or charge | ||||||
18 | for any group life, health, accident, hospital, and
medical | ||||||
19 | insurance.
| ||||||
20 | (c) The corporate authorities may exercise the powers | ||||||
21 | granted in this
Section only if the kinds of group insurance | ||||||
22 | are obtained from an
insurance company authorized to do | ||||||
23 | business
in the State of Illinois,
or are obtained through an
| ||||||
24 | intergovernmental joint self-insurance pool as authorized | ||||||
25 | under the
Intergovernmental Cooperation Act.
The
corporate | ||||||
26 | authorities may enact an ordinance prescribing the method of
|
| |||||||
| |||||||
1 | operation of the insurance program.
| ||||||
2 | (d) If a municipality, including a home rule municipality, | ||||||
3 | is a
self-insurer for purposes of providing health insurance | ||||||
4 | coverage for its
employees, the insurance coverage shall | ||||||
5 | include screening by low-dose
mammography for all women 35 | ||||||
6 | years of age or older for the presence of
occult breast cancer | ||||||
7 | unless the municipality elects to provide mammograms
itself | ||||||
8 | under Section 10-4-2.1. The coverage shall be as follows:
| ||||||
9 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
10 | age.
| ||||||
11 | (2) An annual mammogram for women 40 years of age or | ||||||
12 | older.
| ||||||
13 | Those benefits shall be at least as favorable as for other | ||||||
14 | radiological
examinations and subject to the same dollar | ||||||
15 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
16 | this subsection, "low-dose mammography"
means the x-ray | ||||||
17 | examination of the breast using equipment dedicated
| ||||||
18 | specifically for mammography, including the x-ray tube, | ||||||
19 | filter, compression
device, screens, and image receptors, and | ||||||
20 | cassettes, with an average radiation exposure
delivery of less | ||||||
21 | than one rad mid-breast, with 2 views for each breast. The term | ||||||
22 | also includes digital mammography. The
requirement that | ||||||
23 | mammograms be included in health insurance coverage as
provided | ||||||
24 | in this subsection (d) is an exclusive power and function of | ||||||
25 | the
State and is a denial and limitation under Article VII, | ||||||
26 | Section 6,
subsection (h) of the Illinois Constitution of home |
| |||||||
| |||||||
1 | rule municipality
powers. A home rule municipality to which | ||||||
2 | this subsection applies must
comply with every provision of | ||||||
3 | this subsection.
| ||||||
4 | (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
| ||||||
5 | Section 5-20. The Illinois Insurance Code is amended by | ||||||
6 | changing Section 356g as follows:
| ||||||
7 | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| ||||||
8 | Sec. 356g. Mammograms; mastectomies.
| ||||||
9 | (a) Every insurer shall provide in each group or individual
| ||||||
10 | policy, contract, or certificate of insurance issued or renewed | ||||||
11 | for persons
who are residents of this State, coverage for | ||||||
12 | screening by low-dose
mammography for all women 35 years of age | ||||||
13 | or older for the presence of
occult breast cancer within the | ||||||
14 | provisions of the policy, contract, or
certificate. The | ||||||
15 | coverage shall be as follows:
| ||||||
16 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
17 | age.
| ||||||
18 | (2) An annual mammogram for women 40 years of age or | ||||||
19 | older.
| ||||||
20 | (3) A mammogram at the age and intervals considered | ||||||
21 | medically necessary by the woman's health care provider for | ||||||
22 | women under 40 years of age and having a family history of | ||||||
23 | breast cancer, prior personal history of breast cancer, | ||||||
24 | positive genetic testing, or other risk factors.
|
| |||||||
| |||||||
1 | (4) A comprehensive ultrasound screening of an entire | ||||||
2 | breast or breasts if a mammogram demonstrates | ||||||
3 | heterogeneous or dense breast tissue, when medically | ||||||
4 | necessary as determined by a physician licensed to practice | ||||||
5 | medicine in all of its branches.
| ||||||
6 | These benefits shall be at least as favorable as for other | ||||||
7 | radiological
examinations and subject to the same dollar | ||||||
8 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
9 | this Section, "low-dose mammography"
means the x-ray | ||||||
10 | examination of the breast using equipment dedicated
| ||||||
11 | specifically for mammography, including the x-ray tube, | ||||||
12 | filter, compression
device, screens, and image receptors, and | ||||||
13 | cassettes, receptor , with radiation exposure delivery of less | ||||||
14 | than one
1 rad mid-breast, with per breast for 2 views for each | ||||||
15 | of an average size breast. The term also includes digital | ||||||
16 | mammography.
| ||||||
17 | (b) No policy of accident or health insurance that provides | ||||||
18 | for
the surgical procedure known as a mastectomy shall be | ||||||
19 | issued, amended,
delivered, or renewed in this State unless
| ||||||
20 | that coverage also provides for prosthetic devices
or | ||||||
21 | reconstructive surgery
incident to the mastectomy.
Coverage | ||||||
22 | for breast reconstruction in connection with a mastectomy shall
| ||||||
23 | include:
| ||||||
24 | (1) reconstruction of the breast upon which the | ||||||
25 | mastectomy has been
performed;
| ||||||
26 | (2) surgery and reconstruction of the other breast to |
| |||||||
| |||||||
1 | produce a
symmetrical appearance; and
| ||||||
2 | (3) prostheses and treatment for physical | ||||||
3 | complications at all stages of
mastectomy, including | ||||||
4 | lymphedemas.
| ||||||
5 | Care shall be determined in consultation with the attending | ||||||
6 | physician and the
patient.
The offered coverage for prosthetic | ||||||
7 | devices and
reconstructive surgery shall be subject to the | ||||||
8 | deductible and coinsurance
conditions applied to the | ||||||
9 | mastectomy, and all other terms and conditions
applicable to | ||||||
10 | other benefits. When a mastectomy is performed and there is
no | ||||||
11 | evidence of malignancy then the offered coverage may be limited | ||||||
12 | to the
provision of prosthetic devices and reconstructive | ||||||
13 | surgery to within 2
years after the date of the mastectomy. As | ||||||
14 | used in this Section,
"mastectomy" means the removal of all or | ||||||
15 | part of the breast for medically
necessary reasons, as | ||||||
16 | determined by a licensed physician.
| ||||||
17 | Written notice of the availability of coverage under this | ||||||
18 | Section shall be
delivered to the insured upon enrollment and | ||||||
19 | annually thereafter. An insurer
may not deny to an insured | ||||||
20 | eligibility, or continued eligibility, to enroll or
to renew | ||||||
21 | coverage under the terms of the plan solely for the purpose of
| ||||||
22 | avoiding the requirements of this Section. An insurer may not | ||||||
23 | penalize or
reduce or
limit the reimbursement of an attending | ||||||
24 | provider or provide incentives
(monetary or otherwise) to an | ||||||
25 | attending provider to induce the provider to
provide care to an | ||||||
26 | insured in a manner inconsistent with this Section.
|
| |||||||
| |||||||
1 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||||||
2 | Section 5-25. The Health Maintenance Organization Act is | ||||||
3 | amended by changing Section 4-6.1 as follows:
| ||||||
4 | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| ||||||
5 | Sec. 4-6.1. Mammograms; mastectomies.
| ||||||
6 | (a) Every contract or evidence of coverage
issued by a | ||||||
7 | Health Maintenance Organization for persons who are residents | ||||||
8 | of
this State shall contain coverage for screening by low-dose | ||||||
9 | mammography
for all women 35 years of age or older for the | ||||||
10 | presence of occult breast
cancer. The coverage shall be as | ||||||
11 | follows:
| ||||||
12 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
13 | age.
| ||||||
14 | (2) An annual mammogram for women 40 years of age or | ||||||
15 | older.
| ||||||
16 | (3) A mammogram at the age and intervals considered | ||||||
17 | medically necessary by the woman's health care provider for | ||||||
18 | women under 40 years of age and having a family history of | ||||||
19 | breast cancer, prior personal history of breast cancer, | ||||||
20 | positive genetic testing, or other risk factors. | ||||||
21 | (4) A comprehensive ultrasound screening of an entire | ||||||
22 | breast or breasts if a mammogram demonstrates | ||||||
23 | heterogeneous or dense breast tissue, when medically | ||||||
24 | necessary as determined by a physician licensed to practice |
| |||||||
| |||||||
1 | medicine in all of its branches.
| ||||||
2 | These benefits shall be at least as favorable as for other | ||||||
3 | radiological
examinations and subject to the same dollar | ||||||
4 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
5 | this Section, "low-dose mammography"
means the x-ray | ||||||
6 | examination of the breast using equipment dedicated
| ||||||
7 | specifically for mammography, including the x-ray tube, | ||||||
8 | filter, compression
device, screens, and image receptors, and | ||||||
9 | cassettes, receptor , with radiation exposure delivery of less | ||||||
10 | than one 1
rad mid-breast, with per breast for 2 views for each | ||||||
11 | of an average size breast. The term also includes digital | ||||||
12 | mammography.
| ||||||
13 | (b) No contract or evidence of coverage issued by a health | ||||||
14 | maintenance
organization that provides for the
surgical | ||||||
15 | procedure known as a mastectomy shall be issued, amended, | ||||||
16 | delivered,
or renewed in this State on or after the effective | ||||||
17 | date of this amendatory Act
of the 92nd General Assembly unless | ||||||
18 | that coverage also provides for prosthetic
devices or | ||||||
19 | reconstructive surgery incident to the mastectomy, providing | ||||||
20 | that
the mastectomy is performed after the effective date of | ||||||
21 | this amendatory Act.
Coverage for breast reconstruction in | ||||||
22 | connection
with a mastectomy shall
include:
| ||||||
23 | (1) reconstruction of the breast upon which the | ||||||
24 | mastectomy has been
performed;
| ||||||
25 | (2) surgery and reconstruction of the other breast to | ||||||
26 | produce a
symmetrical appearance; and
|
| |||||||
| |||||||
1 | (3) prostheses and treatment for physical | ||||||
2 | complications at all stages of
mastectomy, including | ||||||
3 | lymphedemas.
| ||||||
4 | Care shall be determined in consultation with the attending | ||||||
5 | physician and the
patient.
The offered coverage for prosthetic | ||||||
6 | devices and
reconstructive surgery shall be subject to the | ||||||
7 | deductible and coinsurance
conditions applied to the | ||||||
8 | mastectomy and all other terms and conditions
applicable to | ||||||
9 | other benefits. When a mastectomy is performed and there is
no | ||||||
10 | evidence of malignancy, then the offered coverage may be | ||||||
11 | limited to the
provision of prosthetic devices and | ||||||
12 | reconstructive surgery to within 2
years after the date of the | ||||||
13 | mastectomy. As used in this Section,
"mastectomy" means the | ||||||
14 | removal of all or part of the breast for medically
necessary | ||||||
15 | reasons, as determined by a licensed physician.
| ||||||
16 | Written notice of the availability of coverage under this | ||||||
17 | Section shall be
delivered to the enrollee upon enrollment and | ||||||
18 | annually thereafter. A
health maintenance organization may not | ||||||
19 | deny to an enrollee eligibility, or
continued eligibility, to | ||||||
20 | enroll or
to renew coverage under the terms of the plan solely | ||||||
21 | for the purpose of
avoiding the requirements of this Section. A | ||||||
22 | health maintenance organization
may not penalize or
reduce or
| ||||||
23 | limit the reimbursement of an attending provider or provide | ||||||
24 | incentives
(monetary or otherwise) to an attending provider to | ||||||
25 | induce the provider to
provide care to an insured in a manner | ||||||
26 | inconsistent with this Section.
|
| |||||||
| |||||||
1 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||||||
2 | Article 10. Breast Cancer Patients' | ||||||
3 | Access To Pain Relief | ||||||
4 | Section 10-5. The Illinois Insurance Code is amended by | ||||||
5 | adding Section 356g.5-1 as follows: | ||||||
6 | (215 ILCS 5/356g.5-1 new) | ||||||
7 | Sec. 356g.5-1. Breast cancer pain medication and therapy. A | ||||||
8 | group or individual policy of accident and health insurance or | ||||||
9 | managed care plan that is amended, delivered, issued, or | ||||||
10 | renewed after the effective date of this amendatory Act of the | ||||||
11 | 95th General Assembly must provide coverage for all medically | ||||||
12 | necessary pain medication and pain therapy related to the | ||||||
13 | treatment of breast cancer on the same terms and conditions | ||||||
14 | that are generally applicable to coverage for other conditions. | ||||||
15 | For purposes of this Section, "pain therapy" means pain therapy | ||||||
16 | that is medically based and includes reasonably defined goals, | ||||||
17 | including, but not limited to, stabilizing or reducing pain, | ||||||
18 | with periodic evaluations of the efficacy of the pain therapy | ||||||
19 | against these goals. The provisions of this Section do not | ||||||
20 | apply to short-term travel, accident-only, limited, or | ||||||
21 | specified-disease policies, or to policies or contracts | ||||||
22 | designed for issuance to persons eligible for coverage under | ||||||
23 | Title XVIII of the Social Security Act, known as Medicare, or |
| |||||||
| |||||||
1 | any other similar coverage under State or federal governmental | ||||||
2 | plans. | ||||||
3 | Section 10-10. The State Employees Group Insurance Act of | ||||||
4 | 1971 is amended by changing Section 6.11 as follows:
| ||||||
5 | (5 ILCS 375/6.11)
| ||||||
6 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
7 | Code
requirements. The program of health
benefits shall provide | ||||||
8 | the post-mastectomy care benefits required to be covered
by a | ||||||
9 | policy of accident and health insurance under Section 356t of | ||||||
10 | the Illinois
Insurance Code. The program of health benefits | ||||||
11 | shall provide the coverage
required under Sections 356g.5, | ||||||
12 | 356g.5-1,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | ||||||
13 | and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | ||||||
14 | of health benefits must comply with Section 155.37 of the
| ||||||
15 | Illinois Insurance Code.
| ||||||
16 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
17 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
18 | Section 10-15. The Counties Code is amended by changing | ||||||
19 | Section 5-1069.3 as follows: | ||||||
20 | (55 ILCS 5/5-1069.3)
| ||||||
21 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
22 | including a home
rule
county, is a self-insurer for purposes of |
| |||||||
| |||||||
1 | providing health insurance coverage
for its employees, the | ||||||
2 | coverage shall include coverage for the post-mastectomy
care | ||||||
3 | benefits required to be covered by a policy of accident and | ||||||
4 | health
insurance under Section 356t and the coverage required | ||||||
5 | under Sections 356g.5, 356g.5-1, 356u,
356w, 356x, 356z.6, and | ||||||
6 | 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | ||||||
7 | requirement that health benefits be covered
as provided in this | ||||||
8 | Section is an
exclusive power and function of the State and is | ||||||
9 | a denial and limitation under
Article VII, Section 6, | ||||||
10 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
11 | to which this Section applies must comply with every provision | ||||||
12 | of
this Section.
| ||||||
13 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
14 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
15 | Section 10-20. The Illinois Municipal Code is amended by | ||||||
16 | changing Section 10-4-2.3 as follows: | ||||||
17 | (65 ILCS 5/10-4-2.3)
| ||||||
18 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
19 | municipality, including a
home rule municipality, is a | ||||||
20 | self-insurer for purposes of providing health
insurance | ||||||
21 | coverage for its employees, the coverage shall include coverage | ||||||
22 | for
the post-mastectomy care benefits required to be covered by | ||||||
23 | a policy of
accident and health insurance under Section 356t | ||||||
24 | and the coverage required
under Sections 356g.5, 356g.5-1, |
| |||||||
| |||||||
1 | 356u, 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | ||||||
2 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
3 | be covered as provided in this is an exclusive power and | ||||||
4 | function of
the State and is a denial and limitation under | ||||||
5 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
6 | Constitution. A home rule municipality to which
this Section | ||||||
7 | applies must comply with every provision of this Section.
| ||||||
8 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
9 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
10 | Section 10-25. The School Code is amended by changing | ||||||
11 | Section 10-22.3f as follows: | ||||||
12 | (105 ILCS 5/10-22.3f)
| ||||||
13 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
14 | protection and
benefits
for employees shall provide the | ||||||
15 | post-mastectomy care benefits required to be
covered by a | ||||||
16 | policy of accident and health insurance under Section 356t and | ||||||
17 | the
coverage required under Sections 356g.5, 356g.5-1, 356u, | ||||||
18 | 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
| ||||||
19 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
20 | revised 12-4-07.)
| ||||||
21 | Section 10-30. The Health Maintenance Organization Act is | ||||||
22 | amended by changing Section 5-3 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
2 | Sec. 5-3. Insurance Code provisions.
| ||||||
3 | (a) Health Maintenance Organizations
shall be subject to | ||||||
4 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
5 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
6 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
7 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
8 | 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
9 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
10 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | ||||||
11 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
12 | XXV, and XXVI of the Illinois Insurance Code.
| ||||||
13 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
14 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
15 | Maintenance Organizations in
the following categories are | ||||||
16 | deemed to be "domestic companies":
| ||||||
17 | (1) a corporation authorized under the
Dental Service | ||||||
18 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
19 | (2) a corporation organized under the laws of this | ||||||
20 | State; or
| ||||||
21 | (3) a corporation organized under the laws of another | ||||||
22 | state, 30% or more
of the enrollees of which are residents | ||||||
23 | of this State, except a
corporation subject to | ||||||
24 | substantially the same requirements in its state of
| ||||||
25 | organization as is a "domestic company" under Article VIII | ||||||
26 | 1/2 of the
Illinois Insurance Code.
|
| |||||||
| |||||||
1 | (c) In considering the merger, consolidation, or other | ||||||
2 | acquisition of
control of a Health Maintenance Organization | ||||||
3 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
4 | (1) the Director shall give primary consideration to | ||||||
5 | the continuation of
benefits to enrollees and the financial | ||||||
6 | conditions of the acquired Health
Maintenance Organization | ||||||
7 | after the merger, consolidation, or other
acquisition of | ||||||
8 | control takes effect;
| ||||||
9 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
10 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
11 | apply and (ii) the Director, in making
his determination | ||||||
12 | with respect to the merger, consolidation, or other
| ||||||
13 | acquisition of control, need not take into account the | ||||||
14 | effect on
competition of the merger, consolidation, or | ||||||
15 | other acquisition of control;
| ||||||
16 | (3) the Director shall have the power to require the | ||||||
17 | following
information:
| ||||||
18 | (A) certification by an independent actuary of the | ||||||
19 | adequacy
of the reserves of the Health Maintenance | ||||||
20 | Organization sought to be acquired;
| ||||||
21 | (B) pro forma financial statements reflecting the | ||||||
22 | combined balance
sheets of the acquiring company and | ||||||
23 | the Health Maintenance Organization sought
to be | ||||||
24 | acquired as of the end of the preceding year and as of | ||||||
25 | a date 90 days
prior to the acquisition, as well as pro | ||||||
26 | forma financial statements
reflecting projected |
| |||||||
| |||||||
1 | combined operation for a period of 2 years;
| ||||||
2 | (C) a pro forma business plan detailing an | ||||||
3 | acquiring party's plans with
respect to the operation | ||||||
4 | of the Health Maintenance Organization sought to
be | ||||||
5 | acquired for a period of not less than 3 years; and
| ||||||
6 | (D) such other information as the Director shall | ||||||
7 | require.
| ||||||
8 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
9 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
10 | any health maintenance
organization of greater than 10% of its
| ||||||
11 | enrollee population (including without limitation the health | ||||||
12 | maintenance
organization's right, title, and interest in and to | ||||||
13 | its health care
certificates).
| ||||||
14 | (e) In considering any management contract or service | ||||||
15 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
16 | Code, the Director (i) shall, in
addition to the criteria | ||||||
17 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
18 | into account the effect of the management contract or
service | ||||||
19 | agreement on the continuation of benefits to enrollees and the
| ||||||
20 | financial condition of the health maintenance organization to | ||||||
21 | be managed or
serviced, and (ii) need not take into account the | ||||||
22 | effect of the management
contract or service agreement on | ||||||
23 | competition.
| ||||||
24 | (f) Except for small employer groups as defined in the | ||||||
25 | Small Employer
Rating, Renewability and Portability Health | ||||||
26 | Insurance Act and except for
medicare supplement policies as |
| |||||||
| |||||||
1 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
2 | Maintenance Organization may by contract agree with a
group or | ||||||
3 | other enrollment unit to effect refunds or charge additional | ||||||
4 | premiums
under the following terms and conditions:
| ||||||
5 | (i) the amount of, and other terms and conditions with | ||||||
6 | respect to, the
refund or additional premium are set forth | ||||||
7 | in the group or enrollment unit
contract agreed in advance | ||||||
8 | of the period for which a refund is to be paid or
| ||||||
9 | additional premium is to be charged (which period shall not | ||||||
10 | be less than one
year); and
| ||||||
11 | (ii) the amount of the refund or additional premium | ||||||
12 | shall not exceed 20%
of the Health Maintenance | ||||||
13 | Organization's profitable or unprofitable experience
with | ||||||
14 | respect to the group or other enrollment unit for the | ||||||
15 | period (and, for
purposes of a refund or additional | ||||||
16 | premium, the profitable or unprofitable
experience shall | ||||||
17 | be calculated taking into account a pro rata share of the
| ||||||
18 | Health Maintenance Organization's administrative and | ||||||
19 | marketing expenses, but
shall not include any refund to be | ||||||
20 | made or additional premium to be paid
pursuant to this | ||||||
21 | subsection (f)). The Health Maintenance Organization and | ||||||
22 | the
group or enrollment unit may agree that the profitable | ||||||
23 | or unprofitable
experience may be calculated taking into | ||||||
24 | account the refund period and the
immediately preceding 2 | ||||||
25 | plan years.
| ||||||
26 | The Health Maintenance Organization shall include a |
| |||||||
| |||||||
1 | statement in the
evidence of coverage issued to each enrollee | ||||||
2 | describing the possibility of a
refund or additional premium, | ||||||
3 | and upon request of any group or enrollment unit,
provide to | ||||||
4 | the group or enrollment unit a description of the method used | ||||||
5 | to
calculate (1) the Health Maintenance Organization's | ||||||
6 | profitable experience with
respect to the group or enrollment | ||||||
7 | unit and the resulting refund to the group
or enrollment unit | ||||||
8 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
9 | experience with respect to the group or enrollment unit and the | ||||||
10 | resulting
additional premium to be paid by the group or | ||||||
11 | enrollment unit.
| ||||||
12 | In no event shall the Illinois Health Maintenance | ||||||
13 | Organization
Guaranty Association be liable to pay any | ||||||
14 | contractual obligation of an
insolvent organization to pay any | ||||||
15 | refund authorized under this Section.
| ||||||
16 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
17 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
18 | Section 10-35. The Voluntary Health Services Plans Act is | ||||||
19 | amended by changing Section 10 as follows:
| ||||||
20 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
21 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
22 | services
plan corporations and all persons interested therein | ||||||
23 | or dealing therewith
shall be subject to the provisions of | ||||||
24 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, |
| |||||||
| |||||||
1 | 149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u, | ||||||
2 | 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||||
3 | 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | ||||||
4 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
5 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
6 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
7 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
8 | 8-28-07; revised 12-5-07.)
| ||||||
9 | Article 15. Reducing Financial Barriers To Mammography | ||||||
10 | Section 15-5. The Illinois Insurance Code is amended by | ||||||
11 | changing Section 356g as follows:
| ||||||
12 | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| ||||||
13 | Sec. 356g. Mammograms; mastectomies.
| ||||||
14 | (a) Every insurer shall provide in each group or individual
| ||||||
15 | policy, contract, or certificate of insurance issued or renewed | ||||||
16 | for persons
who are residents of this State, coverage for | ||||||
17 | screening by low-dose
mammography for all women 35 years of age | ||||||
18 | or older for the presence of
occult breast cancer within the | ||||||
19 | provisions of the policy, contract, or
certificate. The | ||||||
20 | coverage shall be as follows:
| ||||||
21 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
22 | age.
| ||||||
23 | (2) An annual mammogram for women 40 years of age or |
| |||||||
| |||||||
1 | older.
| ||||||
2 | (3) A mammogram at the age and intervals considered | ||||||
3 | medically necessary by the woman's health care provider for | ||||||
4 | women under 40 years of age and having a family history of | ||||||
5 | breast cancer, prior personal history of breast cancer, | ||||||
6 | positive genetic testing, or other risk factors.
| ||||||
7 | (4) A comprehensive ultrasound screening of an entire | ||||||
8 | breast or breasts if a mammogram demonstrates | ||||||
9 | heterogeneous or dense breast tissue, when medically | ||||||
10 | necessary as determined by a physician licensed to practice | ||||||
11 | medicine in all of its branches.
| ||||||
12 | These benefits shall be at least as favorable as for other | ||||||
13 | radiological
examinations and subject to the same dollar | ||||||
14 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
15 | this Section, "low-dose mammography"
means the x-ray | ||||||
16 | examination of the breast using equipment dedicated
| ||||||
17 | specifically for mammography, including the x-ray tube, | ||||||
18 | filter, compression
device, and image receptor, with radiation | ||||||
19 | exposure delivery of less than
1 rad per breast for 2 views of | ||||||
20 | an average size breast.
| ||||||
21 | (a-5) Coverage as described by subsection (a) shall be | ||||||
22 | provided at no cost to the insured and shall not be subject to | ||||||
23 | an annual or lifetime maximum benefit. | ||||||
24 | (a-10) When health care services are available through | ||||||
25 | contracted providers and a person does not comply with plan | ||||||
26 | provisions specific to the use of contracted providers, the |
| |||||||
| |||||||
1 | requirements of subsection (a-5) are not applicable. When a | ||||||
2 | person does not comply with plan provisions specific to the use | ||||||
3 | of contracted providers, plan provisions specific to the use of | ||||||
4 | non-contracted providers must be applied without distinction | ||||||
5 | for coverage required by this Section and shall be at least as | ||||||
6 | favorable as for other radiological examinations covered by the | ||||||
7 | policy or contract. | ||||||
8 | (b) No policy of accident or health insurance that provides | ||||||
9 | for
the surgical procedure known as a mastectomy shall be | ||||||
10 | issued, amended,
delivered, or renewed in this State unless
| ||||||
11 | that coverage also provides for prosthetic devices
or | ||||||
12 | reconstructive surgery
incident to the mastectomy.
Coverage | ||||||
13 | for breast reconstruction in connection with a mastectomy shall
| ||||||
14 | include:
| ||||||
15 | (1) reconstruction of the breast upon which the | ||||||
16 | mastectomy has been
performed;
| ||||||
17 | (2) surgery and reconstruction of the other breast to | ||||||
18 | produce a
symmetrical appearance; and
| ||||||
19 | (3) prostheses and treatment for physical | ||||||
20 | complications at all stages of
mastectomy, including | ||||||
21 | lymphedemas.
| ||||||
22 | Care shall be determined in consultation with the attending | ||||||
23 | physician and the
patient.
The offered coverage for prosthetic | ||||||
24 | devices and
reconstructive surgery shall be subject to the | ||||||
25 | deductible and coinsurance
conditions applied to the | ||||||
26 | mastectomy, and all other terms and conditions
applicable to |
| |||||||
| |||||||
1 | other benefits. When a mastectomy is performed and there is
no | ||||||
2 | evidence of malignancy then the offered coverage may be limited | ||||||
3 | to the
provision of prosthetic devices and reconstructive | ||||||
4 | surgery to within 2
years after the date of the mastectomy. As | ||||||
5 | used in this Section,
"mastectomy" means the removal of all or | ||||||
6 | part of the breast for medically
necessary reasons, as | ||||||
7 | determined by a licensed physician.
| ||||||
8 | Written notice of the availability of coverage under this | ||||||
9 | Section shall be
delivered to the insured upon enrollment and | ||||||
10 | annually thereafter. An insurer
may not deny to an insured | ||||||
11 | eligibility, or continued eligibility, to enroll or
to renew | ||||||
12 | coverage under the terms of the plan solely for the purpose of
| ||||||
13 | avoiding the requirements of this Section. An insurer may not | ||||||
14 | penalize or
reduce or
limit the reimbursement of an attending | ||||||
15 | provider or provide incentives
(monetary or otherwise) to an | ||||||
16 | attending provider to induce the provider to
provide care to an | ||||||
17 | insured in a manner inconsistent with this Section.
| ||||||
18 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||||||
19 | Section 15-10. The State Employees Group Insurance Act of | ||||||
20 | 1971 is amended by changing Section 6.11 as follows:
| ||||||
21 | (5 ILCS 375/6.11)
| ||||||
22 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
23 | Code
requirements. The program of health
benefits shall provide | ||||||
24 | the post-mastectomy care benefits required to be covered
by a |
| |||||||
| |||||||
1 | policy of accident and health insurance under Section 356t of | ||||||
2 | the Illinois
Insurance Code. The program of health benefits | ||||||
3 | shall provide the coverage
required under Sections 356g, | ||||||
4 | 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | ||||||
5 | and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | ||||||
6 | of health benefits must comply with Section 155.37 of the
| ||||||
7 | Illinois Insurance Code.
| ||||||
8 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
9 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
10 | Section 15-15. The Counties Code is amended by changing | ||||||
11 | Sections 5-1069 and 5-1069.3 as follows:
| ||||||
12 | (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
| ||||||
13 | Sec. 5-1069. Group life, health, accident, hospital, and | ||||||
14 | medical
insurance.
| ||||||
15 | (a) The county board of any county may arrange to provide, | ||||||
16 | for
the benefit of employees of the county, group life, health, | ||||||
17 | accident, hospital,
and medical insurance, or any one or any | ||||||
18 | combination of those types of
insurance, or the county board | ||||||
19 | may self-insure, for the benefit of its
employees, all or a | ||||||
20 | portion of the employees' group life, health, accident,
| ||||||
21 | hospital, and medical insurance, or any one or any combination | ||||||
22 | of those
types of insurance, including a combination of | ||||||
23 | self-insurance and other
types of insurance authorized by this | ||||||
24 | Section, provided that the county
board complies with all other |
| |||||||
| |||||||
1 | requirements of this Section. The insurance
may include | ||||||
2 | provision for employees who rely on treatment by prayer or
| ||||||
3 | spiritual means alone for healing in accordance with the tenets | ||||||
4 | and
practice of a well recognized religious denomination. The | ||||||
5 | county board may
provide for payment by the county of a portion | ||||||
6 | or all of the premium or
charge for the insurance with the | ||||||
7 | employee paying the balance of the
premium or charge, if any. | ||||||
8 | If the county board undertakes a plan under
which the county | ||||||
9 | pays only a portion of the premium or charge, the county
board | ||||||
10 | shall provide for withholding and deducting from the | ||||||
11 | compensation of
those employees who consent to join the plan | ||||||
12 | the balance of the premium or
charge for the insurance.
| ||||||
13 | (b) If the county board does not provide for self-insurance | ||||||
14 | or for a plan
under which the county pays a portion or all of | ||||||
15 | the premium or charge for a
group insurance plan, the county | ||||||
16 | board may provide for withholding and
deducting from the | ||||||
17 | compensation of those employees who consent thereto the
total | ||||||
18 | premium or charge for any group life, health, accident, | ||||||
19 | hospital, and
medical insurance.
| ||||||
20 | (c) The county board may exercise the powers granted in | ||||||
21 | this Section only if
it provides for self-insurance or, where | ||||||
22 | it makes arrangements to provide
group insurance through an | ||||||
23 | insurance carrier, if the kinds of group
insurance are obtained | ||||||
24 | from an insurance company authorized to do business
in the | ||||||
25 | State of Illinois. The county board may enact an ordinance
| ||||||
26 | prescribing the method of operation of the insurance program.
|
| |||||||
| |||||||
1 | (d) If a county, including a home rule county, is a | ||||||
2 | self-insurer for
purposes of providing health insurance | ||||||
3 | coverage for its employees, the
insurance coverage shall | ||||||
4 | include screening by low-dose mammography for all
women 35 | ||||||
5 | years of age or older for the presence of occult breast cancer
| ||||||
6 | unless the county elects to provide mammograms itself under | ||||||
7 | Section
5-1069.1. The coverage shall be as follows:
| ||||||
8 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
9 | age.
| ||||||
10 | (2) An annual mammogram for women 40 years of age or | ||||||
11 | older.
| ||||||
12 | Those benefits shall be at least as favorable as for other | ||||||
13 | radiological
examinations and subject to the same dollar | ||||||
14 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
15 | this subsection, "low-dose mammography"
means the x-ray | ||||||
16 | examination of the breast using equipment dedicated
| ||||||
17 | specifically for mammography, including the x-ray tube, | ||||||
18 | filter, compression
device, screens, and image receptors, with | ||||||
19 | an average radiation exposure
delivery of less than one rad | ||||||
20 | mid-breast, with 2 views for each breast. The
requirement that | ||||||
21 | mammograms be included in health insurance coverage as
provided | ||||||
22 | in this subsection (d) is an exclusive power and function of | ||||||
23 | the
State and is a denial and limitation under Article VII, | ||||||
24 | Section 6,
subsection (h) of the Illinois Constitution of home | ||||||
25 | rule county powers. A
home rule county to which this subsection | ||||||
26 | applies must comply with every
provision of this subsection.
|
| |||||||
| |||||||
1 | (e) The term "employees" as used in this Section includes | ||||||
2 | elected or
appointed officials but does not include temporary | ||||||
3 | employees.
| ||||||
4 | (f) The county board may, by ordinance, arrange to provide | ||||||
5 | group life,
health, accident, hospital, and medical insurance, | ||||||
6 | or any one or a combination
of those types of insurance, under | ||||||
7 | this Section to retired former employees and
retired former | ||||||
8 | elected or appointed officials of the county.
| ||||||
9 | (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
| ||||||
10 | (55 ILCS 5/5-1069.3)
| ||||||
11 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
12 | including a home
rule
county, is a self-insurer for purposes of | ||||||
13 | providing health insurance coverage
for its employees, the | ||||||
14 | coverage shall include coverage for the post-mastectomy
care | ||||||
15 | benefits required to be covered by a policy of accident and | ||||||
16 | health
insurance under Section 356t and the coverage required | ||||||
17 | under Sections 356g, 356g.5, 356u,
356w, 356x, 356z.6, and | ||||||
18 | 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | ||||||
19 | requirement that health benefits be covered
as provided in this | ||||||
20 | Section is an
exclusive power and function of the State and is | ||||||
21 | a denial and limitation under
Article VII, Section 6, | ||||||
22 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
23 | to which this Section applies must comply with every provision | ||||||
24 | of
this Section.
| ||||||
25 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; |
| |||||||
| |||||||
1 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
2 | Section 15-20. The Illinois Municipal Code is amended by | ||||||
3 | changing Sections 10-4-2 and 10-4-2.3 as follows:
| ||||||
4 | (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
| ||||||
5 | Sec. 10-4-2. Group insurance.
| ||||||
6 | (a) The corporate authorities of any municipality may | ||||||
7 | arrange
to provide, for the benefit of employees of the | ||||||
8 | municipality, group life,
health, accident, hospital, and | ||||||
9 | medical insurance, or any one or any
combination of those types | ||||||
10 | of insurance, and may arrange to provide that
insurance for the | ||||||
11 | benefit of the spouses or dependents of those employees.
The | ||||||
12 | insurance may include provision for employees or other insured | ||||||
13 | persons
who rely on treatment by prayer or spiritual means | ||||||
14 | alone for healing in
accordance with the tenets and practice of | ||||||
15 | a well recognized religious
denomination. The corporate | ||||||
16 | authorities may provide for payment by the
municipality of a | ||||||
17 | portion of the premium or charge for the insurance with
the | ||||||
18 | employee paying the balance of the premium or charge. If the | ||||||
19 | corporate
authorities undertake a plan under which the | ||||||
20 | municipality pays a portion of
the premium or charge, the | ||||||
21 | corporate authorities shall provide for
withholding and | ||||||
22 | deducting from the compensation of those municipal
employees | ||||||
23 | who consent to join the plan the balance of the premium or | ||||||
24 | charge
for the insurance.
|
| |||||||
| |||||||
1 | (b) If the corporate authorities do not provide for a plan | ||||||
2 | under which
the municipality pays a portion of the premium or | ||||||
3 | charge for a group
insurance plan, the corporate authorities | ||||||
4 | may provide for withholding
and deducting from the compensation | ||||||
5 | of those employees who consent thereto
the premium or charge | ||||||
6 | for any group life, health, accident, hospital, and
medical | ||||||
7 | insurance.
| ||||||
8 | (c) The corporate authorities may exercise the powers | ||||||
9 | granted in this
Section only if the kinds of group insurance | ||||||
10 | are obtained from an
insurance company authorized to do | ||||||
11 | business
in the State of Illinois,
or are obtained through an
| ||||||
12 | intergovernmental joint self-insurance pool as authorized | ||||||
13 | under the
Intergovernmental Cooperation Act.
The
corporate | ||||||
14 | authorities may enact an ordinance prescribing the method of
| ||||||
15 | operation of the insurance program.
| ||||||
16 | (d) If a municipality, including a home rule municipality, | ||||||
17 | is a
self-insurer for purposes of providing health insurance | ||||||
18 | coverage for its
employees, the insurance coverage shall | ||||||
19 | include screening by low-dose
mammography for all women 35 | ||||||
20 | years of age or older for the presence of
occult breast cancer | ||||||
21 | unless the municipality elects to provide mammograms
itself | ||||||
22 | under Section 10-4-2.1. The coverage shall be as follows:
| ||||||
23 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
24 | age.
| ||||||
25 | (2) An annual mammogram for women 40 years of age or | ||||||
26 | older.
|
| |||||||
| |||||||
1 | Those benefits shall be at least as favorable as for other | ||||||
2 | radiological
examinations and subject to the same dollar | ||||||
3 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
4 | this subsection, "low-dose mammography"
means the x-ray | ||||||
5 | examination of the breast using equipment dedicated
| ||||||
6 | specifically for mammography, including the x-ray tube, | ||||||
7 | filter, compression
device, screens, and image receptors, with | ||||||
8 | an average radiation exposure
delivery of less than one rad | ||||||
9 | mid-breast, with 2 views for each breast. The
requirement that | ||||||
10 | mammograms be included in health insurance coverage as
provided | ||||||
11 | in this subsection (d) is an exclusive power and function of | ||||||
12 | the
State and is a denial and limitation under Article VII, | ||||||
13 | Section 6,
subsection (h) of the Illinois Constitution of home | ||||||
14 | rule municipality
powers. A home rule municipality to which | ||||||
15 | this subsection applies must
comply with every provision of | ||||||
16 | this subsection.
| ||||||
17 | (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
| ||||||
18 | (65 ILCS 5/10-4-2.3)
| ||||||
19 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
20 | municipality, including a
home rule municipality, is a | ||||||
21 | self-insurer for purposes of providing health
insurance | ||||||
22 | coverage for its employees, the coverage shall include coverage | ||||||
23 | for
the post-mastectomy care benefits required to be covered by | ||||||
24 | a policy of
accident and health insurance under Section 356t | ||||||
25 | and the coverage required
under Sections 356g, 356g.5, 356u, |
| |||||||
| |||||||
1 | 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | ||||||
2 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
3 | be covered as provided in this is an exclusive power and | ||||||
4 | function of
the State and is a denial and limitation under | ||||||
5 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
6 | Constitution. A home rule municipality to which
this Section | ||||||
7 | applies must comply with every provision of this Section.
| ||||||
8 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
9 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
10 | Section 15-25. The School Code is amended by changing | ||||||
11 | Section 10-22.3f as follows: | ||||||
12 | (105 ILCS 5/10-22.3f)
| ||||||
13 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
14 | protection and
benefits
for employees shall provide the | ||||||
15 | post-mastectomy care benefits required to be
covered by a | ||||||
16 | policy of accident and health insurance under Section 356t and | ||||||
17 | the
coverage required under Sections 356g, 356g.5, 356u, 356w, | ||||||
18 | 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
| ||||||
19 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
20 | revised 12-4-07.)
| ||||||
21 | Section 15-30. The Health Maintenance Organization Act is | ||||||
22 | amended by changing Section 4-6.1 as follows:
|
| |||||||
| |||||||
1 | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| ||||||
2 | Sec. 4-6.1. Mammograms; mastectomies.
| ||||||
3 | (a) Every contract or evidence of coverage
issued by a | ||||||
4 | Health Maintenance Organization for persons who are residents | ||||||
5 | of
this State shall contain coverage for screening by low-dose | ||||||
6 | mammography
for all women 35 years of age or older for the | ||||||
7 | presence of occult breast
cancer. The coverage shall be as | ||||||
8 | follows:
| ||||||
9 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
10 | age.
| ||||||
11 | (2) An annual mammogram for women 40 years of age or | ||||||
12 | older.
| ||||||
13 | (3) A mammogram at the age and intervals considered | ||||||
14 | medically necessary by the woman's health care provider for | ||||||
15 | women under 40 years of age and having a family history of | ||||||
16 | breast cancer, prior personal history of breast cancer, | ||||||
17 | positive genetic testing, or other risk factors. | ||||||
18 | (4) A comprehensive ultrasound screening of an entire | ||||||
19 | breast or breasts if a mammogram demonstrates | ||||||
20 | heterogeneous or dense breast tissue, when medically | ||||||
21 | necessary as determined by a physician licensed to practice | ||||||
22 | medicine in all of its branches.
| ||||||
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 |
| |||||||
| |||||||
1 | examination of the breast using equipment dedicated
| ||||||
2 | specifically for mammography, including the x-ray tube, | ||||||
3 | filter, compression
device, and image receptor, with radiation | ||||||
4 | exposure delivery of less than 1
rad per breast for 2 views of | ||||||
5 | an average size breast.
| ||||||
6 | (a-5) Coverage as described in subsection (a) shall be | ||||||
7 | provided at no cost to the enrollee, shall not be subject to an | ||||||
8 | annual or lifetime maximum benefit, and shall be at least as | ||||||
9 | favorable as for other radiological examinations covered by the | ||||||
10 | policy or contract. | ||||||
11 | (b) No contract or evidence of coverage issued by a health | ||||||
12 | maintenance
organization that provides for the
surgical | ||||||
13 | procedure known as a mastectomy shall be issued, amended, | ||||||
14 | delivered,
or renewed in this State on or after the effective | ||||||
15 | date of this amendatory Act
of the 92nd General Assembly unless | ||||||
16 | that coverage also provides for prosthetic
devices or | ||||||
17 | reconstructive surgery incident to the mastectomy, providing | ||||||
18 | that
the mastectomy is performed after the effective date of | ||||||
19 | this amendatory Act.
Coverage for breast reconstruction in | ||||||
20 | connection
with a mastectomy shall
include:
| ||||||
21 | (1) reconstruction of the breast upon which the | ||||||
22 | mastectomy has been
performed;
| ||||||
23 | (2) surgery and reconstruction of the other breast to | ||||||
24 | produce a
symmetrical appearance; and
| ||||||
25 | (3) prostheses and treatment for physical | ||||||
26 | complications at all stages of
mastectomy, including |
| |||||||
| |||||||
1 | lymphedemas.
| ||||||
2 | Care shall be determined in consultation with the attending | ||||||
3 | physician and the
patient.
The offered coverage for prosthetic | ||||||
4 | devices and
reconstructive surgery shall be subject to the | ||||||
5 | deductible and coinsurance
conditions applied to the | ||||||
6 | mastectomy and all other terms and conditions
applicable to | ||||||
7 | other benefits. When a mastectomy is performed and there is
no | ||||||
8 | evidence of malignancy, then the offered coverage may be | ||||||
9 | limited to the
provision of prosthetic devices and | ||||||
10 | reconstructive surgery to within 2
years after the date of the | ||||||
11 | mastectomy. As used in this Section,
"mastectomy" means the | ||||||
12 | removal of all or part of the breast for medically
necessary | ||||||
13 | reasons, as determined by a licensed physician.
| ||||||
14 | Written notice of the availability of coverage under this | ||||||
15 | Section shall be
delivered to the enrollee upon enrollment and | ||||||
16 | annually thereafter. A
health maintenance organization may not | ||||||
17 | deny to an enrollee eligibility, or
continued eligibility, to | ||||||
18 | enroll or
to renew coverage under the terms of the plan solely | ||||||
19 | for the purpose of
avoiding the requirements of this Section. A | ||||||
20 | health maintenance organization
may not penalize or
reduce or
| ||||||
21 | limit the reimbursement of an attending provider or provide | ||||||
22 | incentives
(monetary or otherwise) to an attending provider to | ||||||
23 | induce the provider to
provide care to an insured in a manner | ||||||
24 | inconsistent with this Section.
| ||||||
25 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
|
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1 | Section 15-35. The Voluntary Health Services Plans Act is | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2 | amended by changing Section 10 as follows:
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3 | (215 ILCS 165/10) (from Ch. 32, par. 604)
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4 | Sec. 10. Application of Insurance Code provisions. Health | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5 | services
plan corporations and all persons interested therein | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6 | or dealing therewith
shall be subject to the provisions of | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9 | 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10 | 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12 | and (15) of Section 367 of the Illinois
Insurance Code.
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13 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15 | 8-28-07; revised 12-5-07.)
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16 | Section 99. Effective date. This Act takes effect upon | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17 | becoming law.
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