103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4421

 

Introduced 1/16/2024, by Rep. Janet Yang Rohr

 

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

    Amends the Illinois Insurance Code. In a provision concerning coverage for mammograms, provides that if a woman's physician has ordered the patient to receive breast tomosynthesis because it has been determined that high breast density will make low-dose mammography inaccurate or ineffective, the insurer shall not require the physician to order an additional low-dose mammography as a precondition to breast tomosynthesis, nor shall an insurer require the patient to receive a low-dose mammography as a precondition to breast tomosynthesis. Provides that if the results of a woman's first 2-dimensional mammogram screening determine that the patient has high breast density, coverage of breast tomosynthesis shall be provided at no cost to the insured, regardless of whether the breast tomosynthesis and 2-dimensional mammogram occurs within the same calendar year, coverage year, or 365-day period.


LRB103 36181 RPS 66273 b

STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT
MAY APPLY

 

 

A BILL FOR

 

HB4421LRB103 36181 RPS 66273 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    Sec. 356g. Mammograms; mastectomies.
8    (a) Every insurer shall provide in each group or
9individual policy, contract, or certificate of insurance
10issued or renewed for persons who are residents of this State,
11coverage for screening by low-dose mammography for all women
1235 years of age or older for the presence of occult breast
13cancer within the provisions of the policy, contract, or
14certificate. The coverage shall be as follows:
15         (1) A baseline mammogram for women 35 to 39 years of
16    age.
17         (2) An annual mammogram for women 40 years of age or
18    older.
19         (3) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider
21    for women under 40 years of age and having a family history
22    of breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.

 

 

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1        (4) For an individual or group policy of accident and
2    health insurance or a managed care plan that is amended,
3    delivered, issued, or renewed on or after the effective
4    date of this amendatory Act of the 101st General Assembly,
5    a comprehensive ultrasound screening and MRI of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue or when medically
8    necessary as determined by a physician licensed to
9    practice medicine in all of its branches.
10        (5) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13        (6) For an individual or group policy of accident and
14    health insurance or a managed care plan that is amended,
15    delivered, issued, or renewed on or after the effective
16    date of this amendatory Act of the 101st General Assembly,
17    a diagnostic mammogram when medically necessary, as
18    determined by a physician licensed to practice medicine in
19    all its branches, advanced practice registered nurse, or
20    physician assistant.
21    If a woman's physician has ordered the patient to receive
22breast tomosynthesis because it has been determined that high
23breast density will make low-dose mammography inaccurate or
24ineffective, the insurer shall not require the physician to
25order an additional low-dose mammography as a precondition to
26breast tomosynthesis, nor shall an insurer require the patient

 

 

HB4421- 3 -LRB103 36181 RPS 66273 b

1to receive a low-dose mammography as a precondition to breast
2tomosynthesis. This paragraph applies to an individual or
3group policy of accident and health insurance or a managed
4care plan that is amended, delivered, issued, or renewed on or
5after the effective date of this amendatory Act of the 103rd
6General Assembly.
7    If the results of a woman's first 2-dimensional mammogram
8screening determine that the patient has high breast density,
9coverage of breast tomosynthesis shall be provided at no cost
10to the insured, regardless of whether the breast tomosynthesis
11and 2-dimensional mammogram occurs within the same calendar
12year, coverage year, or 365-day period. This paragraph applies
13to an individual or group policy of accident and health
14insurance or a managed care plan that is amended, delivered,
15issued, or renewed on or after the effective date of this
16amendatory Act of the 103rd General Assembly.
17    A policy subject to this subsection shall not impose a
18deductible, coinsurance, copayment, or any other cost-sharing
19requirement on the coverage provided; except that this
20sentence does not apply to coverage of diagnostic mammograms
21to the extent such coverage would disqualify a high-deductible
22health plan from eligibility for a health savings account
23pursuant to Section 223 of the Internal Revenue Code (26
24U.S.C. 223).
25    For purposes of this Section:
26    "Diagnostic mammogram" means a mammogram obtained using

 

 

HB4421- 4 -LRB103 36181 RPS 66273 b

1diagnostic mammography.
2    "Diagnostic mammography" means a method of screening that
3is designed to evaluate an abnormality in a breast, including
4an abnormality seen or suspected on a screening mammogram or a
5subjective or objective abnormality otherwise detected in the
6breast.
7    "Low-dose mammography" means the x-ray examination of the
8breast using equipment dedicated specifically for mammography,
9including the x-ray tube, filter, compression device, and
10image receptor, with radiation exposure delivery of less than
111 rad per breast for 2 views of an average size breast. The
12term also includes digital mammography and includes breast
13tomosynthesis. As used in this Section, the term "breast
14tomosynthesis" means a radiologic procedure that involves the
15acquisition of projection images over the stationary breast to
16produce cross-sectional digital three-dimensional images of
17the breast.
18    If, at any time, the Secretary of the United States
19Department of Health and Human Services, or its successor
20agency, promulgates rules or regulations to be published in
21the Federal Register or publishes a comment in the Federal
22Register or issues an opinion, guidance, or other action that
23would require the State, pursuant to any provision of the
24Patient Protection and Affordable Care Act (Public Law
25111-148), including, but not limited to, 42 U.S.C.
2618031(d)(3)(B) or any successor provision, to defray the cost

 

 

HB4421- 5 -LRB103 36181 RPS 66273 b

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

 

 

HB4421- 6 -LRB103 36181 RPS 66273 b

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

 

 

HB4421- 7 -LRB103 36181 RPS 66273 b

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