SB1365 Engrossed LRB095 04641 KBJ 24699 b

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

 

 

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1         (4) A comprehensive ultrasound screening of an entire
2     breast or breasts if a mammogram demonstrates
3     heterogeneous or dense breast tissue, when medically
4     necessary as determined by a physician licensed to practice
5     medicine in all of its branches.
6     These benefits shall be at least as favorable as for other
7 radiological examinations and subject to the same dollar
8 limits, deductibles, and co-insurance factors. For purposes of
9 this Section, "low-dose mammography" means the x-ray
10 examination of the breast using equipment dedicated
11 specifically for mammography, including the x-ray tube,
12 filter, compression device, and image receptor, with radiation
13 exposure delivery of less than 1 rad per breast for 2 views of
14 an average size breast.
15     (b) No policy of accident or health insurance that provides
16 for the surgical procedure known as a mastectomy shall be
17 issued, amended, delivered, or renewed in this State unless
18 that coverage also provides for prosthetic devices or
19 reconstructive surgery incident to the mastectomy. Coverage
20 for breast reconstruction in connection with a mastectomy shall
21 include:
22         (1) reconstruction of the breast upon which the
23     mastectomy has been performed;
24         (2) surgery and reconstruction of the other breast to
25     produce a symmetrical appearance; and
26         (3) prostheses and treatment for physical

 

 

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1     complications at all stages of mastectomy, including
2     lymphedemas.
3 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.
15     Written notice of the availability of coverage under this
16 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
21 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.
25 (Source: P.A. 94-121, eff. 7-6-05.)
 

 

 

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1     Section 10. The Health Maintenance Organization Act is
2 amended by changing Section 4-6.1 as follows:
 
3     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
4     Sec. 4-6.1. Mammograms; mastectomies.
5     (a) Every contract or evidence of coverage issued by a
6 Health Maintenance Organization for persons who are residents
7 of this State shall contain coverage for screening by low-dose
8 mammography for all women 35 years of age or older for the
9 presence of occult breast cancer. The coverage shall be as
10 follows:
11         (1) A baseline mammogram for women 35 to 39 years of
12     age.
13         (2) An annual mammogram for women 40 years of age or
14     older.
15         (3) A mammogram at the age and intervals considered
16     medically necessary by the woman's health care provider for
17     women under 40 years of age and having a family history of
18     breast cancer, 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.)
 
24     Section 99. Effective date. This Act takes effect upon
25 becoming law.