Health & Healthcare Disparities Committee
Filed: 3/13/2008
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1 | AMENDMENT TO HOUSE BILL 5192
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2 | AMENDMENT NO. ______. Amend House Bill 5192 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Article 1. Legislative Intent | ||||||
5 | Section 1-1. Legislative intent. The General Assembly | ||||||
6 | finds that the mortality associated with breast cancer for | ||||||
7 | minority women in Illinois is significantly higher compared to | ||||||
8 | non-minority women. This disparity has grown over the last 2 | ||||||
9 | decades and is unacceptable. A recent New England Journal of | ||||||
10 | Medicine article found that even modest cost-sharing deters | ||||||
11 | women from getting a mammogram. The reduction was most | ||||||
12 | pronounced for those with lower income and less education. Many | ||||||
13 | other studies have found that women with lower family income | ||||||
14 | and those relying on public programs for healthcare access | ||||||
15 | mammography at a lower rate. It is, therefore, the intent of | ||||||
16 | this legislation to decrease health disparities as they relate |
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1 | to breast cancer and to improve access for all women to quality | ||||||
2 | breast cancer screening and treatment where necessary. | ||||||
3 | Article 5. Improving State Healthcare Programs | ||||||
4 | With Respect To | ||||||
5 | Mammography And Breast Cancer Treatment | ||||||
6 | Section 5-5. The Illinois Public Aid Code is amended by | ||||||
7 | changing Section 5-5 as follows: | ||||||
8 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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9 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
10 | rule, shall
determine the quantity and quality of and the rate | ||||||
11 | of reimbursement for the
medical assistance for which
payment | ||||||
12 | will be authorized, and the medical services to be provided,
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13 | which may include all or part of the following: (1) inpatient | ||||||
14 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
15 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
16 | services; (5) physicians'
services whether furnished in the | ||||||
17 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
18 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
19 | care furnished by licensed practitioners; (7)
home health care | ||||||
20 | services; (8) private duty nursing service; (9) clinic
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21 | services; (10) dental services, including prevention and | ||||||
22 | treatment of periodontal disease and dental caries disease for | ||||||
23 | pregnant women; (11) physical therapy and related
services; |
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1 | (12) prescribed drugs, dentures, and prosthetic devices; and
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2 | eyeglasses prescribed by a physician skilled in the diseases of | ||||||
3 | the eye,
or by an optometrist, whichever the person may select; | ||||||
4 | (13) other
diagnostic, screening, preventive, and | ||||||
5 | rehabilitative services; (14)
transportation and such other | ||||||
6 | expenses as may be necessary; (15) medical
treatment of sexual | ||||||
7 | assault survivors, as defined in
Section 1a of the Sexual | ||||||
8 | Assault Survivors Emergency Treatment Act, for
injuries | ||||||
9 | sustained as a result of the sexual assault, including
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10 | examinations and laboratory tests to discover evidence which | ||||||
11 | may be used in
criminal proceedings arising from the sexual | ||||||
12 | assault; (16) the
diagnosis and treatment of sickle cell | ||||||
13 | anemia; and (17)
any other medical care, and any other type of | ||||||
14 | remedial care recognized
under the laws of this State, but not | ||||||
15 | including abortions, or induced
miscarriages or premature | ||||||
16 | births, unless, in the opinion of a physician,
such procedures | ||||||
17 | are necessary for the preservation of the life of the
woman | ||||||
18 | seeking such treatment, or except an induced premature birth
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19 | intended to produce a live viable child and such procedure is | ||||||
20 | necessary
for the health of the mother or her unborn child. The | ||||||
21 | Illinois Department,
by rule, shall prohibit any physician from | ||||||
22 | providing medical assistance
to anyone eligible therefor under | ||||||
23 | this Code where such physician has been
found guilty of | ||||||
24 | performing an abortion procedure in a wilful and wanton
manner | ||||||
25 | upon a woman who was not pregnant at the time such abortion
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26 | procedure was performed. The term "any other type of remedial |
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1 | care" shall
include nursing care and nursing home service for | ||||||
2 | persons who rely on
treatment by spiritual means alone through | ||||||
3 | prayer for healing.
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4 | Notwithstanding any other provision of this Section, a | ||||||
5 | comprehensive
tobacco use cessation program that includes | ||||||
6 | purchasing prescription drugs or
prescription medical devices | ||||||
7 | approved by the Food and Drug administration shall
be covered | ||||||
8 | under the medical assistance
program under this Article for | ||||||
9 | persons who are otherwise eligible for
assistance under this | ||||||
10 | Article.
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11 | Notwithstanding any other provision of this Code, the | ||||||
12 | Illinois
Department may not require, as a condition of payment | ||||||
13 | for any laboratory
test authorized under this Article, that a | ||||||
14 | physician's handwritten signature
appear on the laboratory | ||||||
15 | test order form. The Illinois Department may,
however, impose | ||||||
16 | other appropriate requirements regarding laboratory test
order | ||||||
17 | documentation.
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18 | The Department of Healthcare and Family Services shall | ||||||
19 | provide the following services to
persons
eligible for | ||||||
20 | assistance under this Article who are participating in
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21 | education, training or employment programs operated by the | ||||||
22 | Department of Human
Services as successor to the Department of | ||||||
23 | Public Aid:
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24 | (1) dental services, which shall include but not be | ||||||
25 | limited to
prosthodontics; and
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26 | (2) eyeglasses prescribed by a physician skilled in the |
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1 | diseases of the
eye, or by an optometrist, whichever the | ||||||
2 | person may select.
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3 | The Illinois Department, by rule, may distinguish and | ||||||
4 | classify the
medical services to be provided only in accordance | ||||||
5 | with the classes of
persons designated in Section 5-2.
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6 | The Department of Healthcare and Family Services must | ||||||
7 | provide coverage and reimbursement for amino acid-based | ||||||
8 | elemental formulas, regardless of delivery method, for the | ||||||
9 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
10 | short bowel syndrome when the prescribing physician has issued | ||||||
11 | a written order stating that the amino acid-based elemental | ||||||
12 | formula is medically necessary.
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13 | The Illinois Department shall authorize the provision of, | ||||||
14 | and shall
authorize payment for, screening by low-dose | ||||||
15 | mammography for the presence of
occult breast cancer for women | ||||||
16 | 35 years of age or older who are eligible
for medical | ||||||
17 | assistance under this Article, as follows: | ||||||
18 | (A) A a baseline
mammogram for women 35 to 39 years of | ||||||
19 | age . and an
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20 | (B) An annual mammogram for women 40 years of age or | ||||||
21 | older. | ||||||
22 | (C) A mammogram at the age and intervals considered | ||||||
23 | medically necessary by the woman's health care provider for | ||||||
24 | women under 40 years of age and having a family history of | ||||||
25 | breast cancer, prior personal history of breast cancer, | ||||||
26 | positive genetic testing, or other risk factors. |
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1 | (D) 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 | All screenings
shall
include a physical breast exam, | ||||||
7 | instruction on self-examination and
information regarding the | ||||||
8 | frequency of self-examination and its value as a
preventative | ||||||
9 | tool. For purposes of As used in this Section, "low-dose | ||||||
10 | mammography" means
the x-ray examination of the breast using | ||||||
11 | equipment dedicated specifically
for mammography, including | ||||||
12 | the x-ray tube, filter, compression device,
and image receptor, | ||||||
13 | and cassettes, with an average radiation exposure delivery
of | ||||||
14 | less than one rad per breast for mid-breast, with 2 views of an | ||||||
15 | average size for each breast. The term also includes digital | ||||||
16 | mammography.
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17 | On and after July 1, 2008, screening and diagnostic | ||||||
18 | mammography shall be reimbursed at the same rate as the | ||||||
19 | Medicare program's rates, including the increased | ||||||
20 | reimbursement for digital mammography. | ||||||
21 | The Department shall convene an expert panel including | ||||||
22 | representatives of hospitals, free-standing mammography | ||||||
23 | facilities, and doctors, including radiologists, to establish | ||||||
24 | quality standards. Based on these quality standards, the | ||||||
25 | Department shall provide for bonus payments to mammography | ||||||
26 | facilities meeting the standards for screening and diagnosis. |
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1 | The bonus payments shall be at least 15% higher than the | ||||||
2 | Medicare rates for mammography. | ||||||
3 | Subject to federal approval, the Department shall | ||||||
4 | establish a rate methodology for mammography at federally | ||||||
5 | qualified health centers and other encounter-rate clinics. | ||||||
6 | These clinics or centers may also collaborate with other | ||||||
7 | hospital-based mammography facilities. | ||||||
8 | The Department shall establish a methodology to remind | ||||||
9 | women who are age-appropriate for screening mammography, but | ||||||
10 | who have not received a mammogram within the previous 18 | ||||||
11 | months, of the importance and benefit of screening mammography. | ||||||
12 | The Department shall establish a performance goal for | ||||||
13 | primary care providers with respect to their female patients | ||||||
14 | over age 40 receiving an annual mammogram. This performance | ||||||
15 | goal shall be used to provide additional reimbursement in the | ||||||
16 | form of a quality performance bonus to primary care providers | ||||||
17 | who meet that goal. | ||||||
18 | The Department shall devise a means of case-managing or | ||||||
19 | patient navigation for beneficiaries diagnosed with breast | ||||||
20 | cancer. This program shall initially operate as a pilot program | ||||||
21 | in areas of the State with the highest incidence of mortality | ||||||
22 | related to breast cancer. At least one pilot program site shall | ||||||
23 | be in the metropolitan Chicago area and at least one site shall | ||||||
24 | be outside the metropolitan Chicago area. An evaluation of the | ||||||
25 | pilot program shall be carried out measuring health outcomes | ||||||
26 | and cost of care for those served by the pilot program compared |
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1 | to similarly situated patients who are not served by the pilot | ||||||
2 | program. | ||||||
3 | Any medical or health care provider shall immediately | ||||||
4 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
5 | services and is suspected
of drug abuse or is addicted as | ||||||
6 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
7 | Act, referral to a local substance abuse treatment provider
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8 | licensed by the Department of Human Services or to a licensed
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9 | hospital which provides substance abuse treatment services. | ||||||
10 | The Department of Healthcare and Family Services
shall assure | ||||||
11 | coverage for the cost of treatment of the drug abuse or
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12 | addiction for pregnant recipients in accordance with the | ||||||
13 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
14 | Human Services.
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15 | All medical providers providing medical assistance to | ||||||
16 | pregnant women
under this Code shall receive information from | ||||||
17 | the Department on the
availability of services under the Drug | ||||||
18 | Free Families with a Future or any
comparable program providing | ||||||
19 | case management services for addicted women,
including | ||||||
20 | information on appropriate referrals for other social services
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21 | that may be needed by addicted women in addition to treatment | ||||||
22 | for addiction.
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23 | The Illinois Department, in cooperation with the | ||||||
24 | Departments of Human
Services (as successor to the Department | ||||||
25 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
26 | public awareness campaign, may
provide information concerning |
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1 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
2 | health care, and other pertinent programs directed at
reducing | ||||||
3 | the number of drug-affected infants born to recipients of | ||||||
4 | medical
assistance.
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5 | Neither the Department of Healthcare and Family Services | ||||||
6 | nor the Department of Human
Services shall sanction the | ||||||
7 | recipient solely on the basis of
her substance abuse.
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8 | The Illinois Department shall establish such regulations | ||||||
9 | governing
the dispensing of health services under this Article | ||||||
10 | as it shall deem
appropriate. The Department
should
seek the | ||||||
11 | advice of formal professional advisory committees appointed by
| ||||||
12 | the Director of the Illinois Department for the purpose of | ||||||
13 | providing regular
advice on policy and administrative matters, | ||||||
14 | information dissemination and
educational activities for | ||||||
15 | medical and health care providers, and
consistency in | ||||||
16 | procedures to the Illinois Department.
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17 | The Illinois Department may develop and contract with | ||||||
18 | Partnerships of
medical providers to arrange medical services | ||||||
19 | for persons eligible under
Section 5-2 of this Code. | ||||||
20 | Implementation of this Section may be by
demonstration projects | ||||||
21 | in certain geographic areas. The Partnership shall
be | ||||||
22 | represented by a sponsor organization. The Department, by rule, | ||||||
23 | shall
develop qualifications for sponsors of Partnerships. | ||||||
24 | Nothing in this
Section shall be construed to require that the | ||||||
25 | sponsor organization be a
medical organization.
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26 | The sponsor must negotiate formal written contracts with |
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1 | medical
providers for physician services, inpatient and | ||||||
2 | outpatient hospital care,
home health services, treatment for | ||||||
3 | alcoholism and substance abuse, and
other services determined | ||||||
4 | necessary by the Illinois Department by rule for
delivery by | ||||||
5 | Partnerships. Physician services must include prenatal and
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6 | obstetrical care. The Illinois Department shall reimburse | ||||||
7 | medical services
delivered by Partnership providers to clients | ||||||
8 | in target areas according to
provisions of this Article and the | ||||||
9 | Illinois Health Finance Reform Act,
except that:
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10 | (1) Physicians participating in a Partnership and | ||||||
11 | providing certain
services, which shall be determined by | ||||||
12 | the Illinois Department, to persons
in areas covered by the | ||||||
13 | Partnership may receive an additional surcharge
for such | ||||||
14 | services.
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15 | (2) The Department may elect to consider and negotiate | ||||||
16 | financial
incentives to encourage the development of | ||||||
17 | Partnerships and the efficient
delivery of medical care.
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18 | (3) Persons receiving medical services through | ||||||
19 | Partnerships may receive
medical and case management | ||||||
20 | services above the level usually offered
through the | ||||||
21 | medical assistance program.
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22 | Medical providers shall be required to meet certain | ||||||
23 | qualifications to
participate in Partnerships to ensure the | ||||||
24 | delivery of high quality medical
services. These | ||||||
25 | qualifications shall be determined by rule of the Illinois
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26 | Department and may be higher than qualifications for |
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1 | participation in the
medical assistance program. Partnership | ||||||
2 | sponsors may prescribe reasonable
additional qualifications | ||||||
3 | for participation by medical providers, only with
the prior | ||||||
4 | written approval of the Illinois Department.
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5 | Nothing in this Section shall limit the free choice of | ||||||
6 | practitioners,
hospitals, and other providers of medical | ||||||
7 | services by clients.
In order to ensure patient freedom of | ||||||
8 | choice, the Illinois Department shall
immediately promulgate | ||||||
9 | all rules and take all other necessary actions so that
provided | ||||||
10 | services may be accessed from therapeutically certified | ||||||
11 | optometrists
to the full extent of the Illinois Optometric | ||||||
12 | Practice Act of 1987 without
discriminating between service | ||||||
13 | providers.
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14 | The Department shall apply for a waiver from the United | ||||||
15 | States Health
Care Financing Administration to allow for the | ||||||
16 | implementation of
Partnerships under this Section.
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17 | The Illinois Department shall require health care | ||||||
18 | providers to maintain
records that document the medical care | ||||||
19 | and services provided to recipients
of Medical Assistance under | ||||||
20 | this Article. The Illinois Department shall
require health care | ||||||
21 | providers to make available, when authorized by the
patient, in | ||||||
22 | writing, the medical records in a timely fashion to other
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23 | health care providers who are treating or serving persons | ||||||
24 | eligible for
Medical Assistance under this Article. All | ||||||
25 | dispensers of medical services
shall be required to maintain | ||||||
26 | and retain business and professional records
sufficient to |
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1 | fully and accurately document the nature, scope, details and
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2 | receipt of the health care provided to persons eligible for | ||||||
3 | medical
assistance under this Code, in accordance with | ||||||
4 | regulations promulgated by
the Illinois Department. The rules | ||||||
5 | and regulations shall require that proof
of the receipt of | ||||||
6 | prescription drugs, dentures, prosthetic devices and
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7 | eyeglasses by eligible persons under this Section accompany | ||||||
8 | each claim
for reimbursement submitted by the dispenser of such | ||||||
9 | medical services.
No such claims for reimbursement shall be | ||||||
10 | approved for payment by the Illinois
Department without such | ||||||
11 | proof of receipt, unless the Illinois Department
shall have put | ||||||
12 | into effect and shall be operating a system of post-payment
| ||||||
13 | audit and review which shall, on a sampling basis, be deemed | ||||||
14 | adequate by
the Illinois Department to assure that such drugs, | ||||||
15 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
16 | is being made are actually being
received by eligible | ||||||
17 | recipients. Within 90 days after the effective date of
this | ||||||
18 | amendatory Act of 1984, the Illinois Department shall establish | ||||||
19 | a
current list of acquisition costs for all prosthetic devices | ||||||
20 | and any
other items recognized as medical equipment and | ||||||
21 | supplies reimbursable under
this Article and shall update such | ||||||
22 | list on a quarterly basis, except that
the acquisition costs of | ||||||
23 | all prescription drugs shall be updated no
less frequently than | ||||||
24 | every 30 days as required by Section 5-5.12.
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25 | The rules and regulations of the Illinois Department shall | ||||||
26 | require
that a written statement including the required opinion |
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1 | of a physician
shall accompany any claim for reimbursement for | ||||||
2 | abortions, or induced
miscarriages or premature births. This | ||||||
3 | statement shall indicate what
procedures were used in providing | ||||||
4 | such medical services.
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5 | The Illinois Department shall require all dispensers of | ||||||
6 | medical
services, other than an individual practitioner or | ||||||
7 | group of practitioners,
desiring to participate in the Medical | ||||||
8 | Assistance program
established under this Article to disclose | ||||||
9 | all financial, beneficial,
ownership, equity, surety or other | ||||||
10 | interests in any and all firms,
corporations, partnerships, | ||||||
11 | associations, business enterprises, joint
ventures, agencies, | ||||||
12 | institutions or other legal entities providing any
form of | ||||||
13 | health care services in this State under this Article.
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14 | The Illinois Department may require that all dispensers of | ||||||
15 | medical
services desiring to participate in the medical | ||||||
16 | assistance program
established under this Article disclose, | ||||||
17 | under such terms and conditions as
the Illinois Department may | ||||||
18 | by rule establish, all inquiries from clients
and attorneys | ||||||
19 | regarding medical bills paid by the Illinois Department, which
| ||||||
20 | inquiries could indicate potential existence of claims or liens | ||||||
21 | for the
Illinois Department.
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22 | Enrollment of a vendor that provides non-emergency medical | ||||||
23 | transportation,
defined by the Department by rule,
shall be
| ||||||
24 | conditional for 180 days. During that time, the Department of | ||||||
25 | Healthcare and Family Services may
terminate the vendor's | ||||||
26 | eligibility to participate in the medical assistance
program |
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1 | without cause. That termination of eligibility is not subject | ||||||
2 | to the
Department's hearing process.
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3 | The Illinois Department shall establish policies, | ||||||
4 | procedures,
standards and criteria by rule for the acquisition, | ||||||
5 | repair and replacement
of orthotic and prosthetic devices and | ||||||
6 | durable medical equipment. Such
rules shall provide, but not be | ||||||
7 | limited to, the following services: (1)
immediate repair or | ||||||
8 | replacement of such devices by recipients without
medical | ||||||
9 | authorization; and (2) rental, lease, purchase or | ||||||
10 | lease-purchase of
durable medical equipment in a | ||||||
11 | cost-effective manner, taking into
consideration the | ||||||
12 | recipient's medical prognosis, the extent of the
recipient's | ||||||
13 | needs, and the requirements and costs for maintaining such
| ||||||
14 | equipment. Such rules shall enable a recipient to temporarily | ||||||
15 | acquire and
use alternative or substitute devices or equipment | ||||||
16 | pending repairs or
replacements of any device or equipment | ||||||
17 | previously authorized for such
recipient by the Department.
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18 | The Department shall execute, relative to the nursing home | ||||||
19 | prescreening
project, written inter-agency agreements with the | ||||||
20 | Department of Human
Services and the Department on Aging, to | ||||||
21 | effect the following: (i) intake
procedures and common | ||||||
22 | eligibility criteria for those persons who are receiving
| ||||||
23 | non-institutional services; and (ii) the establishment and | ||||||
24 | development of
non-institutional services in areas of the State | ||||||
25 | where they are not currently
available or are undeveloped.
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26 | The Illinois Department shall develop and operate, in |
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1 | cooperation
with other State Departments and agencies and in | ||||||
2 | compliance with
applicable federal laws and regulations, | ||||||
3 | appropriate and effective
systems of health care evaluation and | ||||||
4 | programs for monitoring of
utilization of health care services | ||||||
5 | and facilities, as it affects
persons eligible for medical | ||||||
6 | assistance under this Code.
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7 | The Illinois Department shall report annually to the | ||||||
8 | General Assembly,
no later than the second Friday in April of | ||||||
9 | 1979 and each year
thereafter, in regard to:
| ||||||
10 | (a) actual statistics and trends in utilization of | ||||||
11 | medical services by
public aid recipients;
| ||||||
12 | (b) actual statistics and trends in the provision of | ||||||
13 | the various medical
services by medical vendors;
| ||||||
14 | (c) current rate structures and proposed changes in | ||||||
15 | those rate structures
for the various medical vendors; and
| ||||||
16 | (d) efforts at utilization review and control by the | ||||||
17 | Illinois Department.
| ||||||
18 | The period covered by each report shall be the 3 years | ||||||
19 | ending on the June
30 prior to the report. The report shall | ||||||
20 | include suggested legislation
for consideration by the General | ||||||
21 | Assembly. The filing of one copy of the
report with the | ||||||
22 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
23 | the Clerk of the House of Representatives, one copy with the | ||||||
24 | President,
one copy with the Minority Leader and one copy with | ||||||
25 | the Secretary of the
Senate, one copy with the Legislative | ||||||
26 | Research Unit, and such additional
copies
with the State |
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| |||||||
1 | Government Report Distribution Center for the General
Assembly | ||||||
2 | as is required under paragraph (t) of Section 7 of the State
| ||||||
3 | Library Act shall be deemed sufficient to comply with this | ||||||
4 | Section.
| ||||||
5 | (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
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6 | Article 10. Breast Cancer Patients' | ||||||
7 | Access To Pain Relief | ||||||
8 | Section 10-5. The Illinois Insurance Code is amended by | ||||||
9 | adding Section 356g.5-1 as follows: | ||||||
10 | (215 ILCS 5/356g.5-1 new) | ||||||
11 | Sec. 356g.5-1. Breast cancer pain medication and therapy. A | ||||||
12 | group or individual policy of accident and health insurance or | ||||||
13 | managed care plan that is amended, delivered, issued, or | ||||||
14 | renewed after the effective date of this amendatory Act of the | ||||||
15 | 95th General Assembly must provide coverage for all medically | ||||||
16 | necessary pain medication and pain therapy related to the | ||||||
17 | treatment of breast cancer on the same terms and conditions | ||||||
18 | that are generally applicable to coverage for other conditions. | ||||||
19 | For purposes of this Section, "pain therapy" means pain therapy | ||||||
20 | that is medically based and includes reasonably defined goals, | ||||||
21 | including, but not limited to, stabilizing or reducing pain, | ||||||
22 | with periodic evaluations of the efficacy of the pain therapy | ||||||
23 | against these goals. The provisions of this Section do not |
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| |||||||
1 | apply to short-term travel, accident-only, limited, or | ||||||
2 | specified-disease policies, or to policies or contracts | ||||||
3 | designed for issuance to persons eligible for coverage under | ||||||
4 | Title XVIII of the Social Security Act, known as Medicare, or | ||||||
5 | any other similar coverage under State or federal governmental | ||||||
6 | plans. | ||||||
7 | Section 10-10. The State Employees Group Insurance Act of | ||||||
8 | 1971 is amended by changing Section 6.11 as follows:
| ||||||
9 | (5 ILCS 375/6.11)
| ||||||
10 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
11 | Code
requirements. The program of health
benefits shall provide | ||||||
12 | the post-mastectomy care benefits required to be covered
by a | ||||||
13 | policy of accident and health insurance under Section 356t of | ||||||
14 | the Illinois
Insurance Code. The program of health benefits | ||||||
15 | shall provide the coverage
required under Sections 356g.5, | ||||||
16 | 356g.5-1,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | ||||||
17 | and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | ||||||
18 | of health benefits must comply with Section 155.37 of the
| ||||||
19 | Illinois Insurance Code.
| ||||||
20 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
21 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
22 | Section 10-15. The Counties Code is amended by changing | ||||||
23 | Section 5-1069.3 as follows: |
| |||||||
| |||||||
1 | (55 ILCS 5/5-1069.3)
| ||||||
2 | Sec. 5-1069.3. Required health benefits. If a county, | ||||||
3 | including a home
rule
county, is a self-insurer for purposes of | ||||||
4 | providing health insurance coverage
for its employees, the | ||||||
5 | coverage shall include coverage for the post-mastectomy
care | ||||||
6 | benefits required to be covered by a policy of accident and | ||||||
7 | health
insurance under Section 356t and the coverage required | ||||||
8 | under Sections 356g.5, 356g.5-1, 356u,
356w, 356x, 356z.6, and | ||||||
9 | 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | ||||||
10 | requirement that health benefits be covered
as provided in this | ||||||
11 | Section is an
exclusive power and function of the State and is | ||||||
12 | a denial and limitation under
Article VII, Section 6, | ||||||
13 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
14 | to which this Section applies must comply with every provision | ||||||
15 | of
this Section.
| ||||||
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 10-20. The Illinois Municipal Code is amended by | ||||||
19 | changing Section 10-4-2.3 as follows: | ||||||
20 | (65 ILCS 5/10-4-2.3)
| ||||||
21 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
22 | municipality, including a
home rule municipality, is a | ||||||
23 | self-insurer for purposes of providing health
insurance |
| |||||||
| |||||||
1 | coverage for its employees, the coverage shall include coverage | ||||||
2 | for
the post-mastectomy care benefits required to be covered by | ||||||
3 | a policy of
accident and health insurance under Section 356t | ||||||
4 | and the coverage required
under Sections 356g.5, 356g.5-1, | ||||||
5 | 356u, 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | ||||||
6 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
7 | be covered as provided in this is an exclusive power and | ||||||
8 | function of
the State and is a denial and limitation under | ||||||
9 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
10 | Constitution. A home rule municipality to which
this Section | ||||||
11 | applies must comply with every provision of this Section.
| ||||||
12 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
13 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
14 | Section 10-25. The School Code is amended by changing | ||||||
15 | Section 10-22.3f as follows: | ||||||
16 | (105 ILCS 5/10-22.3f)
| ||||||
17 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
18 | protection and
benefits
for employees shall provide the | ||||||
19 | post-mastectomy care benefits required to be
covered by a | ||||||
20 | policy of accident and health insurance under Section 356t and | ||||||
21 | the
coverage required under Sections 356g.5, 356g.5-1, 356u, | ||||||
22 | 356w, 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
| ||||||
23 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
24 | revised 12-4-07.)
|
| |||||||
| |||||||
1 | Section 10-30. The Health Maintenance Organization Act is | ||||||
2 | amended by changing Section 5-3 as follows:
| ||||||
3 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
4 | Sec. 5-3. Insurance Code provisions.
| ||||||
5 | (a) Health Maintenance Organizations
shall be subject to | ||||||
6 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
7 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
8 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
9 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
10 | 356z.10
356z.9 , 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, | ||||||
11 | 368d, 368e, 370c,
401, 401.1, 402, 403, 403A,
408, 408.2, 409, | ||||||
12 | 412, 444,
and
444.1,
paragraph (c) of subsection (2) of Section | ||||||
13 | 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, | ||||||
14 | XXV, and XXVI of the Illinois Insurance Code.
| ||||||
15 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
16 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
17 | Maintenance Organizations in
the following categories are | ||||||
18 | deemed to be "domestic companies":
| ||||||
19 | (1) a corporation authorized under the
Dental Service | ||||||
20 | Plan Act or the Voluntary Health Services Plans Act;
| ||||||
21 | (2) a corporation organized under the laws of this | ||||||
22 | State; or
| ||||||
23 | (3) a corporation organized under the laws of another | ||||||
24 | state, 30% or more
of the enrollees of which are residents |
| |||||||
| |||||||
1 | of this State, except a
corporation subject to | ||||||
2 | substantially the same requirements in its state of
| ||||||
3 | organization as is a "domestic company" under Article VIII | ||||||
4 | 1/2 of the
Illinois Insurance Code.
| ||||||
5 | (c) In considering the merger, consolidation, or other | ||||||
6 | acquisition of
control of a Health Maintenance Organization | ||||||
7 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
8 | (1) the Director shall give primary consideration to | ||||||
9 | the continuation of
benefits to enrollees and the financial | ||||||
10 | conditions of the acquired Health
Maintenance Organization | ||||||
11 | after the merger, consolidation, or other
acquisition of | ||||||
12 | control takes effect;
| ||||||
13 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
14 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
15 | apply and (ii) the Director, in making
his determination | ||||||
16 | with respect to the merger, consolidation, or other
| ||||||
17 | acquisition of control, need not take into account the | ||||||
18 | effect on
competition of the merger, consolidation, or | ||||||
19 | other acquisition of control;
| ||||||
20 | (3) the Director shall have the power to require the | ||||||
21 | following
information:
| ||||||
22 | (A) certification by an independent actuary of the | ||||||
23 | adequacy
of the reserves of the Health Maintenance | ||||||
24 | Organization sought to be acquired;
| ||||||
25 | (B) pro forma financial statements reflecting the | ||||||
26 | combined balance
sheets of the acquiring company and |
| |||||||
| |||||||
1 | the Health Maintenance Organization sought
to be | ||||||
2 | acquired as of the end of the preceding year and as of | ||||||
3 | a date 90 days
prior to the acquisition, as well as pro | ||||||
4 | forma financial statements
reflecting projected | ||||||
5 | combined operation for a period of 2 years;
| ||||||
6 | (C) a pro forma business plan detailing an | ||||||
7 | acquiring party's plans with
respect to the operation | ||||||
8 | of the Health Maintenance Organization sought to
be | ||||||
9 | acquired for a period of not less than 3 years; and
| ||||||
10 | (D) such other information as the Director shall | ||||||
11 | require.
| ||||||
12 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
13 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
14 | any health maintenance
organization of greater than 10% of its
| ||||||
15 | enrollee population (including without limitation the health | ||||||
16 | maintenance
organization's right, title, and interest in and to | ||||||
17 | its health care
certificates).
| ||||||
18 | (e) In considering any management contract or service | ||||||
19 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
20 | Code, the Director (i) shall, in
addition to the criteria | ||||||
21 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
22 | into account the effect of the management contract or
service | ||||||
23 | agreement on the continuation of benefits to enrollees and the
| ||||||
24 | financial condition of the health maintenance organization to | ||||||
25 | be managed or
serviced, and (ii) need not take into account the | ||||||
26 | effect of the management
contract or service agreement on |
| |||||||
| |||||||
1 | competition.
| ||||||
2 | (f) Except for small employer groups as defined in the | ||||||
3 | Small Employer
Rating, Renewability and Portability Health | ||||||
4 | Insurance Act and except for
medicare supplement policies as | ||||||
5 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
6 | Maintenance Organization may by contract agree with a
group or | ||||||
7 | other enrollment unit to effect refunds or charge additional | ||||||
8 | premiums
under the following terms and conditions:
| ||||||
9 | (i) the amount of, and other terms and conditions with | ||||||
10 | respect to, the
refund or additional premium are set forth | ||||||
11 | in the group or enrollment unit
contract agreed in advance | ||||||
12 | of the period for which a refund is to be paid or
| ||||||
13 | additional premium is to be charged (which period shall not | ||||||
14 | be less than one
year); and
| ||||||
15 | (ii) the amount of the refund or additional premium | ||||||
16 | shall not exceed 20%
of the Health Maintenance | ||||||
17 | Organization's profitable or unprofitable experience
with | ||||||
18 | respect to the group or other enrollment unit for the | ||||||
19 | period (and, for
purposes of a refund or additional | ||||||
20 | premium, the profitable or unprofitable
experience shall | ||||||
21 | be calculated taking into account a pro rata share of the
| ||||||
22 | Health Maintenance Organization's administrative and | ||||||
23 | marketing expenses, but
shall not include any refund to be | ||||||
24 | made or additional premium to be paid
pursuant to this | ||||||
25 | subsection (f)). The Health Maintenance Organization and | ||||||
26 | the
group or enrollment unit may agree that the profitable |
| |||||||
| |||||||
1 | or unprofitable
experience may be calculated taking into | ||||||
2 | account the refund period and the
immediately preceding 2 | ||||||
3 | plan years.
| ||||||
4 | The Health Maintenance Organization shall include a | ||||||
5 | statement in the
evidence of coverage issued to each enrollee | ||||||
6 | describing the possibility of a
refund or additional premium, | ||||||
7 | and upon request of any group or enrollment unit,
provide to | ||||||
8 | the group or enrollment unit a description of the method used | ||||||
9 | to
calculate (1) the Health Maintenance Organization's | ||||||
10 | profitable experience with
respect to the group or enrollment | ||||||
11 | unit and the resulting refund to the group
or enrollment unit | ||||||
12 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
13 | experience with respect to the group or enrollment unit and the | ||||||
14 | resulting
additional premium to be paid by the group or | ||||||
15 | enrollment unit.
| ||||||
16 | In no event shall the Illinois Health Maintenance | ||||||
17 | Organization
Guaranty Association be liable to pay any | ||||||
18 | contractual obligation of an
insolvent organization to pay any | ||||||
19 | refund authorized under this Section.
| ||||||
20 | (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06; | ||||||
21 | 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
22 | Section 10-35. The Voluntary Health Services Plans Act is | ||||||
23 | amended by changing Section 10 as follows:
| ||||||
24 | (215 ILCS 165/10) (from Ch. 32, par. 604)
|
| |||||||
| |||||||
1 | Sec. 10. Application of Insurance Code provisions. Health | ||||||
2 | services
plan corporations and all persons interested therein | ||||||
3 | or dealing therewith
shall be subject to the provisions of | ||||||
4 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
5 | 149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u, | ||||||
6 | 356v,
356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||||
7 | 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | ||||||
8 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
9 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
10 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
11 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
12 | 8-28-07; revised 12-5-07.)
| ||||||
13 | Article 15. Reducing Financial Barriers To Mammography | ||||||
14 | Section 15-5. The Illinois Insurance Code is amended by | ||||||
15 | changing Section 356g as follows:
| ||||||
16 | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| ||||||
17 | Sec. 356g. Mammograms; mastectomies.
| ||||||
18 | (a) Every insurer shall provide in each group or individual
| ||||||
19 | policy, contract, or certificate of insurance issued or renewed | ||||||
20 | for persons
who are residents of this State, coverage for | ||||||
21 | screening by low-dose
mammography for all women 35 years of age | ||||||
22 | or older for the presence of
occult breast cancer within the | ||||||
23 | provisions of the policy, contract, or
certificate. The |
| |||||||
| |||||||
1 | coverage shall be as follows:
| ||||||
2 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
3 | age.
| ||||||
4 | (2) An annual mammogram for women 40 years of age or | ||||||
5 | older.
| ||||||
6 | (3) A mammogram at the age and intervals considered | ||||||
7 | medically necessary by the woman's health care provider for | ||||||
8 | women under 40 years of age and having a family history of | ||||||
9 | breast cancer, prior personal history of breast cancer, | ||||||
10 | positive genetic testing, or other risk factors.
| ||||||
11 | (4) A comprehensive ultrasound screening of an entire | ||||||
12 | breast or breasts if a mammogram demonstrates | ||||||
13 | heterogeneous or dense breast tissue, when medically | ||||||
14 | necessary as determined by a physician licensed to practice | ||||||
15 | medicine in all of its branches.
| ||||||
16 | These benefits shall be at least as favorable as for other | ||||||
17 | radiological
examinations and subject to the same dollar | ||||||
18 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
19 | this Section, "low-dose mammography"
means the x-ray | ||||||
20 | examination of the breast using equipment dedicated
| ||||||
21 | specifically for mammography, including the x-ray tube, | ||||||
22 | filter, compression
device, and image receptor, with radiation | ||||||
23 | exposure delivery of less than
1 rad per breast for 2 views of | ||||||
24 | an average size breast. The term also includes digital | ||||||
25 | mammography.
| ||||||
26 | (a-5) Coverage as described by subsection (a) shall be |
| |||||||
| |||||||
1 | provided at no cost to the insured and shall not be applied to | ||||||
2 | an annual or lifetime maximum benefit. | ||||||
3 | (a-10) When health care services are available through | ||||||
4 | contracted providers and a person does not comply with plan | ||||||
5 | provisions specific to the use of contracted providers, the | ||||||
6 | requirements of subsection (a-5) are not applicable. When a | ||||||
7 | person does not comply with plan provisions specific to the use | ||||||
8 | of contracted providers, plan provisions specific to the use of | ||||||
9 | non-contracted providers must be applied without distinction | ||||||
10 | for coverage required by this Section and shall be at least as | ||||||
11 | favorable as for other radiological examinations covered by the | ||||||
12 | policy or contract. | ||||||
13 | (b) No policy of accident or health insurance that provides | ||||||
14 | for
the surgical procedure known as a mastectomy shall be | ||||||
15 | issued, amended,
delivered, or renewed in this State unless
| ||||||
16 | that coverage also provides for prosthetic devices
or | ||||||
17 | reconstructive surgery
incident to the mastectomy.
Coverage | ||||||
18 | for breast reconstruction in connection with a mastectomy shall
| ||||||
19 | include:
| ||||||
20 | (1) reconstruction of the breast upon which the | ||||||
21 | mastectomy has been
performed;
| ||||||
22 | (2) surgery and reconstruction of the other breast to | ||||||
23 | produce a
symmetrical appearance; and
| ||||||
24 | (3) prostheses and treatment for physical | ||||||
25 | complications at all stages of
mastectomy, including | ||||||
26 | lymphedemas.
|
| |||||||
| |||||||
1 | Care shall be determined in consultation with the attending | ||||||
2 | physician and the
patient.
The offered coverage for prosthetic | ||||||
3 | devices and
reconstructive surgery shall be subject to the | ||||||
4 | deductible and coinsurance
conditions applied to the | ||||||
5 | mastectomy, and all other terms and conditions
applicable to | ||||||
6 | other benefits. When a mastectomy is performed and there is
no | ||||||
7 | evidence of malignancy then the offered coverage may be limited | ||||||
8 | to the
provision of prosthetic devices and reconstructive | ||||||
9 | surgery to within 2
years after the date of the mastectomy. As | ||||||
10 | used in this Section,
"mastectomy" means the removal of all or | ||||||
11 | part of the breast for medically
necessary reasons, as | ||||||
12 | determined by a licensed physician.
| ||||||
13 | Written notice of the availability of coverage under this | ||||||
14 | Section shall be
delivered to the insured upon enrollment and | ||||||
15 | annually thereafter. An insurer
may not deny to an insured | ||||||
16 | eligibility, or continued eligibility, to enroll or
to renew | ||||||
17 | coverage under the terms of the plan solely for the purpose of
| ||||||
18 | avoiding the requirements of this Section. An insurer may not | ||||||
19 | penalize or
reduce or
limit the reimbursement of an attending | ||||||
20 | provider or provide incentives
(monetary or otherwise) to an | ||||||
21 | attending provider to induce the provider to
provide care to an | ||||||
22 | insured in a manner inconsistent with this Section.
| ||||||
23 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||||||
24 | Section 15-10. The State Employees Group Insurance Act of | ||||||
25 | 1971 is amended by changing Section 6.11 as follows:
|
| |||||||
| |||||||
1 | (5 ILCS 375/6.11)
| ||||||
2 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
3 | Code
requirements. The program of health
benefits shall provide | ||||||
4 | the post-mastectomy care benefits required to be covered
by a | ||||||
5 | policy of accident and health insurance under Section 356t of | ||||||
6 | the Illinois
Insurance Code. The program of health benefits | ||||||
7 | shall provide the coverage
required under Sections 356g, | ||||||
8 | 356g.5,
356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9, | ||||||
9 | and 356z.10
356z.9 of the
Illinois Insurance Code.
The program | ||||||
10 | of health benefits must comply with Section 155.37 of the
| ||||||
11 | Illinois Insurance Code.
| ||||||
12 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
13 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
14 | Section 15-15. The Counties Code is amended by changing | ||||||
15 | Sections 5-1069 and 5-1069.3 as follows:
| ||||||
16 | (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
| ||||||
17 | Sec. 5-1069. Group life, health, accident, hospital, and | ||||||
18 | medical
insurance.
| ||||||
19 | (a) The county board of any county may arrange to provide, | ||||||
20 | for
the benefit of employees of the county, group life, health, | ||||||
21 | accident, hospital,
and medical insurance, or any one or any | ||||||
22 | combination of those types of
insurance, or the county board | ||||||
23 | may self-insure, for the benefit of its
employees, all or a |
| |||||||
| |||||||
1 | portion of the employees' group life, health, accident,
| ||||||
2 | hospital, and medical insurance, or any one or any combination | ||||||
3 | of those
types of insurance, including a combination of | ||||||
4 | self-insurance and other
types of insurance authorized by this | ||||||
5 | Section, provided that the county
board complies with all other | ||||||
6 | requirements of this Section. The insurance
may include | ||||||
7 | provision for employees who rely on treatment by prayer or
| ||||||
8 | spiritual means alone for healing in accordance with the tenets | ||||||
9 | and
practice of a well recognized religious denomination. The | ||||||
10 | county board may
provide for payment by the county of a portion | ||||||
11 | or all of the premium or
charge for the insurance with the | ||||||
12 | employee paying the balance of the
premium or charge, if any. | ||||||
13 | If the county board undertakes a plan under
which the county | ||||||
14 | pays only a portion of the premium or charge, the county
board | ||||||
15 | shall provide for withholding and deducting from the | ||||||
16 | compensation of
those employees who consent to join the plan | ||||||
17 | the balance of the premium or
charge for the insurance.
| ||||||
18 | (b) If the county board does not provide for self-insurance | ||||||
19 | or for a plan
under which the county pays a portion or all of | ||||||
20 | the premium or charge for a
group insurance plan, the county | ||||||
21 | board may provide for withholding and
deducting from the | ||||||
22 | compensation of those employees who consent thereto the
total | ||||||
23 | premium or charge for any group life, health, accident, | ||||||
24 | hospital, and
medical insurance.
| ||||||
25 | (c) The county board may exercise the powers granted in | ||||||
26 | this Section only if
it provides for self-insurance or, where |
| |||||||
| |||||||
1 | it makes arrangements to provide
group insurance through an | ||||||
2 | insurance carrier, if the kinds of group
insurance are obtained | ||||||
3 | from an insurance company authorized to do business
in the | ||||||
4 | State of Illinois. The county board may enact an ordinance
| ||||||
5 | prescribing the method of operation of the insurance program.
| ||||||
6 | (d) If a county, including a home rule county, is a | ||||||
7 | self-insurer for
purposes of providing health insurance | ||||||
8 | coverage for its employees, the
insurance coverage shall | ||||||
9 | include screening by low-dose mammography for all
women 35 | ||||||
10 | years of age or older for the presence of occult breast cancer
| ||||||
11 | unless the county elects to provide mammograms itself under | ||||||
12 | Section
5-1069.1. The coverage shall be as follows:
| ||||||
13 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
14 | age.
| ||||||
15 | (2) An annual mammogram for women 40 years of age or | ||||||
16 | older.
| ||||||
17 | (3) A mammogram at the age and intervals considered | ||||||
18 | medically necessary by the woman's health care provider for | ||||||
19 | women under 40 years of age and having a family history of | ||||||
20 | breast cancer, prior personal history of breast cancer, | ||||||
21 | positive genetic testing, or other risk factors. | ||||||
22 | (4) A comprehensive ultrasound screening of an entire | ||||||
23 | breast or breasts if a mammogram demonstrates | ||||||
24 | heterogeneous or dense breast tissue, when medically | ||||||
25 | necessary as determined by a physician licensed to practice | ||||||
26 | medicine in all of its branches. |
| |||||||
| |||||||
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 receptor | ||||||
8 | receptors , with an average radiation exposure
delivery of less | ||||||
9 | than one rad per breast for mid-breast, with 2 views of an | ||||||
10 | average size for each breast. The term also includes digital | ||||||
11 | mammography. | ||||||
12 | (d-5) Coverage as described by subsection (d) shall be | ||||||
13 | provided at no cost to the insured and shall not be applied to | ||||||
14 | an annual or lifetime maximum benefit. | ||||||
15 | (d-10) When health care services are available through | ||||||
16 | contracted providers and a person does not comply with plan | ||||||
17 | provisions specific to the use of contracted providers, the | ||||||
18 | requirements of subsection (d-5) are not applicable. When a | ||||||
19 | person does not comply with plan provisions specific to the use | ||||||
20 | of contracted providers, plan provisions specific to the use of | ||||||
21 | non-contracted providers must be applied without distinction | ||||||
22 | for coverage required by this Section and shall be at least as | ||||||
23 | favorable as for other radiological examinations covered by the | ||||||
24 | policy or contract. | ||||||
25 | (d-15) If a county, including a home rule county, is a | ||||||
26 | self-insurer for purposes of providing health insurance |
| |||||||
| |||||||
1 | coverage for its employees, the insurance coverage shall | ||||||
2 | include mastectomy coverage, which includes coverage for | ||||||
3 | prosthetic devices or reconstructive surgery incident to the | ||||||
4 | mastectomy. Coverage for breast reconstruction in connection | ||||||
5 | with a mastectomy shall include: | ||||||
6 | (1) reconstruction of the breast upon which the | ||||||
7 | mastectomy has been performed; | ||||||
8 | (2) surgery and reconstruction of the other breast to | ||||||
9 | produce a symmetrical appearance; and | ||||||
10 | (3) prostheses and treatment for physical | ||||||
11 | complications at all stages of mastectomy, including | ||||||
12 | lymphedemas. | ||||||
13 | Care shall be determined in consultation with the attending | ||||||
14 | physician and the patient. The offered coverage for prosthetic | ||||||
15 | devices and reconstructive surgery shall be subject to the | ||||||
16 | deductible and coinsurance conditions applied to the | ||||||
17 | mastectomy, and all other terms and conditions applicable to | ||||||
18 | other benefits. When a mastectomy is performed and there is no | ||||||
19 | evidence of malignancy then the offered coverage may be limited | ||||||
20 | to the provision of prosthetic devices and reconstructive | ||||||
21 | surgery to within 2 years after the date of the mastectomy. As | ||||||
22 | used in this Section, "mastectomy" means the removal of all or | ||||||
23 | part of the breast for medically necessary reasons, as | ||||||
24 | determined by a licensed physician. | ||||||
25 | A county, including a home rule county, that is a | ||||||
26 | self-insurer for purposes of providing health insurance |
| |||||||
| |||||||
1 | coverage for its employees, may not penalize or reduce or limit | ||||||
2 | the reimbursement of an attending provider or provide | ||||||
3 | incentives (monetary or otherwise) to an attending provider to | ||||||
4 | induce the provider to provide care to an insured in a manner | ||||||
5 | inconsistent with this Section. | ||||||
6 | (d-20) The
requirement that mammograms be included in | ||||||
7 | health insurance coverage as
provided in subsections this | ||||||
8 | subsection (d) through (d-15) is an exclusive power and | ||||||
9 | function of the
State and is a denial and limitation under | ||||||
10 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
11 | Constitution of home rule county powers. A
home rule county to | ||||||
12 | which subsections (d) through (d-15) apply this subsection | ||||||
13 | applies must comply with every
provision of those subsections | ||||||
14 | this subsection .
| ||||||
15 | (e) The term "employees" as used in this Section includes | ||||||
16 | elected or
appointed officials but does not include temporary | ||||||
17 | employees.
| ||||||
18 | (f) The county board may, by ordinance, arrange to provide | ||||||
19 | group life,
health, accident, hospital, and medical insurance, | ||||||
20 | or any one or a combination
of those types of insurance, under | ||||||
21 | this Section to retired former employees and
retired former | ||||||
22 | elected or appointed officials of the county.
| ||||||
23 | (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
| ||||||
24 | (55 ILCS 5/5-1069.3)
| ||||||
25 | Sec. 5-1069.3. Required health benefits. If a county, |
| |||||||
| |||||||
1 | including a home
rule
county, is a self-insurer for purposes of | ||||||
2 | providing health insurance coverage
for its employees, the | ||||||
3 | coverage shall include coverage for the post-mastectomy
care | ||||||
4 | benefits required to be covered by a policy of accident and | ||||||
5 | health
insurance under Section 356t and the coverage required | ||||||
6 | under Sections 356g, 356g.5, 356u,
356w, 356x, 356z.6, and | ||||||
7 | 356z.9, and 356z.10
356z.9 of
the Illinois Insurance Code. The | ||||||
8 | requirement that health benefits be covered
as provided in this | ||||||
9 | Section is an
exclusive power and function of the State and is | ||||||
10 | a denial and limitation under
Article VII, Section 6, | ||||||
11 | subsection (h) of the Illinois Constitution. A home
rule county | ||||||
12 | to which this Section applies must comply with every provision | ||||||
13 | of
this Section.
| ||||||
14 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
15 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
16 | Section 15-20. The Illinois Municipal Code is amended by | ||||||
17 | changing Sections 10-4-2 and 10-4-2.3 as follows:
| ||||||
18 | (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
| ||||||
19 | Sec. 10-4-2. Group insurance.
| ||||||
20 | (a) The corporate authorities of any municipality may | ||||||
21 | arrange
to provide, for the benefit of employees of the | ||||||
22 | municipality, group life,
health, accident, hospital, and | ||||||
23 | medical insurance, or any one or any
combination of those types | ||||||
24 | of insurance, and may arrange to provide that
insurance for the |
| |||||||
| |||||||
1 | benefit of the spouses or dependents of those employees.
The | ||||||
2 | insurance may include provision for employees or other insured | ||||||
3 | persons
who rely on treatment by prayer or spiritual means | ||||||
4 | alone for healing in
accordance with the tenets and practice of | ||||||
5 | a well recognized religious
denomination. The corporate | ||||||
6 | authorities may provide for payment by the
municipality of a | ||||||
7 | portion of the premium or charge for the insurance with
the | ||||||
8 | employee paying the balance of the premium or charge. If the | ||||||
9 | corporate
authorities undertake a plan under which the | ||||||
10 | municipality pays a portion of
the premium or charge, the | ||||||
11 | corporate authorities shall provide for
withholding and | ||||||
12 | deducting from the compensation of those municipal
employees | ||||||
13 | who consent to join the plan the balance of the premium or | ||||||
14 | charge
for the insurance.
| ||||||
15 | (b) If the corporate authorities do not provide for a plan | ||||||
16 | under which
the municipality pays a portion of the premium or | ||||||
17 | charge for a group
insurance plan, the corporate authorities | ||||||
18 | may provide for withholding
and deducting from the compensation | ||||||
19 | of those employees who consent thereto
the premium or charge | ||||||
20 | for any group life, health, accident, hospital, and
medical | ||||||
21 | insurance.
| ||||||
22 | (c) The corporate authorities may exercise the powers | ||||||
23 | granted in this
Section only if the kinds of group insurance | ||||||
24 | are obtained from an
insurance company authorized to do | ||||||
25 | business
in the State of Illinois,
or are obtained through an
| ||||||
26 | intergovernmental joint self-insurance pool as authorized |
| |||||||
| |||||||
1 | under the
Intergovernmental Cooperation Act.
The
corporate | ||||||
2 | authorities may enact an ordinance prescribing the method of
| ||||||
3 | operation of the insurance program.
| ||||||
4 | (d) If a municipality, including a home rule municipality, | ||||||
5 | is a
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 municipality elects to provide mammograms
itself | ||||||
10 | under Section 10-4-2.1. 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 | (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, prior personal history of breast cancer, | ||||||
19 | positive genetic testing, or other risk factors. | ||||||
20 | (4) A comprehensive ultrasound screening of an entire | ||||||
21 | breast or breasts if a mammogram demonstrates | ||||||
22 | heterogeneous or dense breast tissue, when medically | ||||||
23 | necessary as determined by a physician licensed to practice | ||||||
24 | medicine in all of its branches. | ||||||
25 | Those benefits shall be at least as favorable as for other | ||||||
26 | radiological
examinations and subject to the same dollar |
| |||||||
| |||||||
1 | limits, deductibles, and
co-insurance factors. For purposes of | ||||||
2 | this subsection, "low-dose mammography"
means the x-ray | ||||||
3 | examination of the breast using equipment dedicated
| ||||||
4 | specifically for mammography, including the x-ray tube, | ||||||
5 | filter, compression
device, screens, and image receptor | ||||||
6 | receptors , with an average radiation exposure
delivery of less | ||||||
7 | than one rad per breast for mid-breast, with 2 views of an | ||||||
8 | average size for each breast. The term also includes digital | ||||||
9 | mammography. | ||||||
10 | (d-5) Coverage as described by subsection (d) shall be | ||||||
11 | provided at no cost to the insured and shall not be applied to | ||||||
12 | an annual or lifetime maximum benefit. | ||||||
13 | (d-10) When health care services are available through | ||||||
14 | contracted providers and a person does not comply with plan | ||||||
15 | provisions specific to the use of contracted providers, the | ||||||
16 | requirements of subsection (d-5) are not applicable. When a | ||||||
17 | person does not comply with plan provisions specific to the use | ||||||
18 | of contracted providers, plan provisions specific to the use of | ||||||
19 | non-contracted providers must be applied without distinction | ||||||
20 | for coverage required by this Section and shall be at least as | ||||||
21 | favorable as for other radiological examinations covered by the | ||||||
22 | policy or contract. | ||||||
23 | (d-15) If a municipality, including a home rule | ||||||
24 | municipality, is a self-insurer for purposes of providing | ||||||
25 | health insurance coverage for its employees, the insurance | ||||||
26 | coverage shall include mastectomy coverage, which includes |
| |||||||
| |||||||
1 | coverage for prosthetic devices or reconstructive surgery | ||||||
2 | incident to the mastectomy. Coverage for breast reconstruction | ||||||
3 | in 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 limited | ||||||
18 | to the provision of prosthetic devices and reconstructive | ||||||
19 | surgery to within 2 years after the date of the mastectomy. As | ||||||
20 | used in this Section, "mastectomy" means the removal of all or | ||||||
21 | part of the breast for medically necessary reasons, as | ||||||
22 | determined by a licensed physician. | ||||||
23 | A municipality, including a home rule municipality, that is | ||||||
24 | a self-insurer for purposes of providing health insurance | ||||||
25 | coverage for its employees, may not penalize or reduce or limit | ||||||
26 | the reimbursement of an attending provider or provide |
| |||||||
| |||||||
1 | incentives (monetary or otherwise) to an attending provider to | ||||||
2 | induce the provider to provide care to an insured in a manner | ||||||
3 | inconsistent with this Section. | ||||||
4 | (d-20) The
requirement that mammograms be included in | ||||||
5 | health insurance coverage as
provided in subsections this | ||||||
6 | subsection (d) through (d-15) is an exclusive power and | ||||||
7 | function of the
State and is a denial and limitation under | ||||||
8 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
9 | Constitution of home rule municipality
powers. A home rule | ||||||
10 | municipality to which subsections (d) through (d-15) apply this | ||||||
11 | subsection applies must
comply with every provision of through | ||||||
12 | subsections this subsection .
| ||||||
13 | (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
| ||||||
14 | (65 ILCS 5/10-4-2.3)
| ||||||
15 | Sec. 10-4-2.3. Required health benefits. If a | ||||||
16 | municipality, including a
home rule municipality, is a | ||||||
17 | self-insurer for purposes of providing health
insurance | ||||||
18 | coverage for its employees, the coverage shall include coverage | ||||||
19 | for
the post-mastectomy care benefits required to be covered by | ||||||
20 | a policy of
accident and health insurance under Section 356t | ||||||
21 | and the coverage required
under Sections 356g, 356g.5, 356u, | ||||||
22 | 356w, 356x, 356z.6, and 356z.9, and 356z.10
356z.9 of the | ||||||
23 | Illinois
Insurance
Code. The requirement that health
benefits | ||||||
24 | be covered as provided in this is an exclusive power and | ||||||
25 | function of
the State and is a denial and limitation under |
| |||||||
| |||||||
1 | Article VII, Section 6,
subsection (h) of the Illinois | ||||||
2 | Constitution. A home rule municipality to which
this Section | ||||||
3 | applies must comply with every provision of this Section.
| ||||||
4 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
5 | 95-520, eff. 8-28-07; revised 12-4-07.)
| ||||||
6 | Section 15-25. The School Code is amended by changing | ||||||
7 | Section 10-22.3f as follows: | ||||||
8 | (105 ILCS 5/10-22.3f)
| ||||||
9 | Sec. 10-22.3f. Required health benefits. Insurance | ||||||
10 | protection and
benefits
for employees shall provide the | ||||||
11 | post-mastectomy care benefits required to be
covered by a | ||||||
12 | policy of accident and health insurance under Section 356t and | ||||||
13 | the
coverage required under Sections 356g, 356g.5, 356u, 356w, | ||||||
14 | 356x,
356z.6, and 356z.9 of
the
Illinois Insurance Code.
| ||||||
15 | (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07; | ||||||
16 | revised 12-4-07.)
| ||||||
17 | Section 15-30. The Health Maintenance Organization Act is | ||||||
18 | amended by changing Section 4-6.1 as follows:
| ||||||
19 | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| ||||||
20 | Sec. 4-6.1. Mammograms; mastectomies.
| ||||||
21 | (a) Every contract or evidence of coverage
issued by a | ||||||
22 | Health Maintenance Organization for persons who are residents |
| |||||||
| |||||||
1 | of
this State shall contain coverage for screening by low-dose | ||||||
2 | mammography
for all women 35 years of age or older for the | ||||||
3 | presence of occult breast
cancer. The coverage shall be as | ||||||
4 | follows:
| ||||||
5 | (1) A baseline mammogram for women 35 to 39 years of | ||||||
6 | age.
| ||||||
7 | (2) An annual mammogram for women 40 years of age or | ||||||
8 | older.
| ||||||
9 | (3) A mammogram at the age and intervals considered | ||||||
10 | medically necessary by the woman's health care provider for | ||||||
11 | women under 40 years of age and having a family history of | ||||||
12 | breast cancer, prior personal history of breast cancer, | ||||||
13 | positive genetic testing, or other risk factors. | ||||||
14 | (4) A comprehensive ultrasound screening of an entire | ||||||
15 | breast or breasts if a mammogram demonstrates | ||||||
16 | heterogeneous or dense breast tissue, when medically | ||||||
17 | necessary as determined by a physician licensed to practice | ||||||
18 | medicine in all of its branches.
| ||||||
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 |
| |||||||
| |||||||
1 | an average size breast. The term also includes digital | ||||||
2 | mammography.
| ||||||
3 | (a-5) Coverage as described in subsection (a) shall be | ||||||
4 | provided at no cost to the enrollee and shall not be applied to | ||||||
5 | an annual or lifetime maximum benefit. | ||||||
6 | (b) No contract or evidence of coverage issued by a health | ||||||
7 | maintenance
organization that provides for the
surgical | ||||||
8 | procedure known as a mastectomy shall be issued, amended, | ||||||
9 | delivered,
or renewed in this State on or after the effective | ||||||
10 | date of this amendatory Act
of the 92nd General Assembly unless | ||||||
11 | that coverage also provides for prosthetic
devices or | ||||||
12 | reconstructive surgery incident to the mastectomy, providing | ||||||
13 | that
the mastectomy is performed after the effective date of | ||||||
14 | this amendatory Act.
Coverage for breast reconstruction in | ||||||
15 | connection
with a mastectomy shall
include:
| ||||||
16 | (1) reconstruction of the breast upon which the | ||||||
17 | mastectomy has been
performed;
| ||||||
18 | (2) surgery and reconstruction of the other breast to | ||||||
19 | produce a
symmetrical appearance; and
| ||||||
20 | (3) prostheses and treatment for physical | ||||||
21 | complications at all stages of
mastectomy, including | ||||||
22 | lymphedemas.
| ||||||
23 | Care shall be determined in consultation with the attending | ||||||
24 | physician and the
patient.
The offered coverage for prosthetic | ||||||
25 | devices and
reconstructive surgery shall be subject to the | ||||||
26 | deductible and coinsurance
conditions applied to the |
| |||||||
| |||||||
1 | mastectomy and all other terms and conditions
applicable to | ||||||
2 | other benefits. When a mastectomy is performed and there is
no | ||||||
3 | evidence of malignancy, then the offered coverage may be | ||||||
4 | limited to the
provision of prosthetic devices and | ||||||
5 | reconstructive surgery to within 2
years after the date of the | ||||||
6 | mastectomy. As used in this Section,
"mastectomy" means the | ||||||
7 | removal of all or part of the breast for medically
necessary | ||||||
8 | reasons, as determined by a licensed physician.
| ||||||
9 | Written notice of the availability of coverage under this | ||||||
10 | Section shall be
delivered to the enrollee upon enrollment and | ||||||
11 | annually thereafter. A
health maintenance organization may not | ||||||
12 | deny to an enrollee eligibility, or
continued eligibility, to | ||||||
13 | enroll or
to renew coverage under the terms of the plan solely | ||||||
14 | for the purpose of
avoiding the requirements of this Section. A | ||||||
15 | health maintenance organization
may not penalize or
reduce or
| ||||||
16 | limit the reimbursement of an attending provider or provide | ||||||
17 | incentives
(monetary or otherwise) to an attending provider to | ||||||
18 | induce the provider to
provide care to an insured in a manner | ||||||
19 | inconsistent with this Section.
| ||||||
20 | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
| ||||||
21 | Section 15-35. The Voluntary Health Services Plans Act is | ||||||
22 | amended by changing Section 10 as follows:
| ||||||
23 | (215 ILCS 165/10) (from Ch. 32, par. 604)
| ||||||
24 | Sec. 10. Application of Insurance Code provisions. Health |
| |||||||
| |||||||
1 | services
plan corporations and all persons interested therein | ||||||
2 | or dealing therewith
shall be subject to the provisions of | ||||||
3 | Articles IIA and XII 1/2 and Sections
3.1, 133, 140, 143, 143c, | ||||||
4 | 149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
| ||||||
5 | 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, | ||||||
6 | 356z.8, 356z.9,
356z.10
356z.9 , 364.01, 367.2, 368a, 401, | ||||||
7 | 401.1,
402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) | ||||||
8 | and (15) of Section 367 of the Illinois
Insurance Code.
| ||||||
9 | (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07; | ||||||
10 | 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff. | ||||||
11 | 8-28-07; revised 12-5-07.)
| ||||||
12 | Section 99. Effective date. This Act takes effect upon | ||||||
13 | becoming law.".
|