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    AN ACT concerning insurance.

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

 
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    Section 5. The Illinois Insurance Code is amended  by 
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changing Section 356g as follows:
 



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



7
    Sec. 356g. Mammograms; mastectomies. 

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    (a) Every insurer shall provide in each group or individual

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policy, contract, or certificate of insurance issued or renewed 
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for persons
who are residents of this State, coverage for 
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screening by low-dose
mammography for all women 35 years of age 
12
or older for the presence of
occult breast cancer within the 
13
provisions of the policy, contract, or
certificate. The 
14
coverage shall be as follows:


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        (1) A baseline mammogram for women 35 to 39 years of 
16
    age.


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

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        (3) A mammogram at the age and intervals considered 
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    medically necessary by the woman's health care provider for 
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    women under 40 years of age and having a family history of 
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    breast cancer, prior personal history of breast cancer, 
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    positive genetic testing, or other risk factors.

 


 






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        (4) A comprehensive ultrasound screening of an entire 
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    breast or breasts if a mammogram demonstrates 
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    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 
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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, and image receptor, with radiation 
13
exposure delivery of less than
1 rad per breast for 2 views of 
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an average size breast.

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    (b) No policy of accident or health insurance that provides 
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for
the surgical procedure known as a mastectomy shall be 
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issued, amended,
delivered, or renewed in this State unless

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

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include:


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


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


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        (3) prostheses and treatment for physical 
 


 






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    complications at all stages of
mastectomy, including 
2
    lymphedemas.

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Care shall be determined in consultation with the attending 
4
physician and the
patient.
The offered coverage for prosthetic 
5
devices and
reconstructive surgery shall be subject to the 
6
deductible and coinsurance
conditions applied to the 
7
mastectomy, and all other terms and conditions
applicable to 
8
other benefits.  When a mastectomy is performed and there is
no 
9
evidence of malignancy then the offered coverage may be limited 
10
to the
provision of prosthetic devices and reconstructive 
11
surgery to within 2
years after the date of the mastectomy. As 
12
used in this Section,
"mastectomy" means the removal of all or 
13
part of the breast for medically
necessary reasons, as 
14
determined by a licensed physician.

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    Written notice of the availability of coverage under this 
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Section shall be
delivered to the insured upon enrollment and 
17
annually thereafter.  An insurer
may not deny to an insured 
18
eligibility, or continued eligibility, to enroll or
to renew 
19
coverage under the terms of the plan solely for the purpose of

20
avoiding the requirements of this Section.  An insurer may not 
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penalize or
reduce or
limit the reimbursement of an attending 
22
provider or provide incentives
(monetary or otherwise) to an 
23
attending provider to induce the provider to
provide care to an 
24
insured in a manner inconsistent with this Section.

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(Source: P.A. 94-121, eff. 7-6-05.)

 
 


 






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



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



4
    Sec. 4-6.1. Mammograms; mastectomies. 

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


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


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

15
        (3) A mammogram at the age and intervals considered 
16
    medically necessary by the woman's health care provider for 
17
    women under 40 years of age and having a family history of 
18
    breast cancer, 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
    These benefits shall be at least as favorable as for other 
 


 






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1
radiological
examinations and subject to the same dollar 
2
limits, deductibles, and
co-insurance factors.  For purposes of 
3
this Section, "low-dose mammography"
means the x-ray 
4
examination of the breast using equipment dedicated

5
specifically for mammography, including the x-ray tube, 
6
filter, compression
device, and image receptor, with radiation 
7
exposure delivery of less than 1
rad per breast for 2 views of 
8
an average size breast.

9
    (b) No contract or evidence of coverage issued by a health 
10
maintenance
organization that provides for the
surgical 
11
procedure known as a mastectomy shall be issued, amended, 
12
delivered,
or renewed in this State on or after the effective 
13
date of this amendatory Act
of the 92nd General Assembly unless 
14
that coverage also provides for prosthetic
devices or 
15
reconstructive surgery incident to the mastectomy, providing 
16
that
the mastectomy is performed after the effective date of 
17
this amendatory Act.
Coverage for breast reconstruction in 
18
connection
with a mastectomy shall
include:


19
        (1) reconstruction of the breast upon which the 
20
    mastectomy has been
performed;


21
        (2) surgery and reconstruction of the other breast to 
22
    produce a
symmetrical appearance; and


23
        (3) prostheses and treatment for physical 
24
    complications at all stages of
mastectomy, including 
25
    lymphedemas.

26
Care shall be determined in consultation with the attending 
 


 






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1
physician and the
patient.
The offered coverage for prosthetic 
2
devices and
reconstructive surgery shall be subject to the 
3
deductible and coinsurance
conditions applied to the 
4
mastectomy and all other terms and conditions
applicable to 
5
other benefits.  When a mastectomy is performed and there is
no 
6
evidence of malignancy, then the offered coverage may be 
7
limited to the
provision of prosthetic devices and 
8
reconstructive surgery to within 2
years after the date of the 
9
mastectomy. As used in this Section,
"mastectomy" means the 
10
removal of all or part of the breast for medically
necessary 
11
reasons, as determined by a licensed physician.

12
    Written notice of the availability of coverage under this 
13
Section shall be
delivered to the enrollee upon enrollment and 
14
annually thereafter.  A
health maintenance organization may not 
15
deny to an enrollee eligibility, or
continued eligibility, to 
16
enroll or
to renew coverage under the terms of the plan solely 
17
for the purpose of
avoiding the requirements of this Section.  A 
18
health maintenance organization
may not penalize or
reduce or

19
limit the reimbursement of an attending provider or provide 
20
incentives
(monetary or otherwise) to an attending provider to 
21
induce the provider to
provide care to an insured in a manner 
22
inconsistent with this Section.

23
(Source: P.A. 94-121, eff. 7-6-05.)

 

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    Section 99. Effective date. This Act takes effect upon 
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becoming law.