Sen. Dan Kotowski

Filed: 3/14/2007

 

 


 

 


 
09500SB1365sam001 LRB095 04641 KBJ 33672 a

1
AMENDMENT TO SENATE BILL 1365

2     AMENDMENT NO. ______. Amend Senate Bill 1365 by replacing
3 everything after the enacting clause with the following:
 
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.

 

 

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1         (2) An annual mammogram for women 40 years of age or
2     older.
3         (3) A mammogram at the age and intervals considered
4     medically necessary by the woman's health care provider for
5     women under 40 years of age and having a family history of
6     breast cancer, prior personal history of breast cancer,
7     positive genetic testing, or other risk factors.
8         (4) A comprehensive ultrasound screening of an entire
9     breast or breasts if a mammogram demonstrates
10     heterogeneous or dense breast tissue, when medically
11     necessary as determined by a physician licensed to practice
12     medicine in all of its branches.
13     These benefits shall be at least as favorable as for other
14 radiological examinations and subject to the same dollar
15 limits, deductibles, and co-insurance factors. For purposes of
16 this Section, "low-dose mammography" means the x-ray
17 examination of the breast using equipment dedicated
18 specifically for mammography, including the x-ray tube,
19 filter, compression device, and image receptor, with radiation
20 exposure delivery of less than 1 rad per breast for 2 views of
21 an average size breast.
22     (b) No policy of accident or health insurance that provides
23 for the surgical procedure known as a mastectomy shall be
24 issued, amended, delivered, or renewed in this State unless
25 that coverage also provides for prosthetic devices or
26 reconstructive surgery incident to the mastectomy. Coverage

 

 

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

 

 

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1 avoiding the requirements of this Section. An insurer may not
2 penalize or reduce or limit the reimbursement of an attending
3 provider or provide incentives (monetary or otherwise) to an
4 attending provider to induce the provider to provide care to an
5 insured in a manner inconsistent with this Section.
6 (Source: P.A. 94-121, eff. 7-6-05.)
 
7     Section 10. The Health Maintenance Organization Act is
8 amended by changing Section 4-6.1 as follows:
 
9     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
10     Sec. 4-6.1. Mammograms; mastectomies.
11     (a) Every contract or evidence of coverage issued by a
12 Health Maintenance Organization for persons who are residents
13 of this State shall contain coverage for screening by low-dose
14 mammography for all women 35 years of age or older for the
15 presence of occult breast cancer. The coverage shall be as
16 follows:
17         (1) A baseline mammogram for women 35 to 39 years of
18     age.
19         (2) An annual mammogram for women 40 years of age or
20     older.
21         (3) A mammogram at the age and intervals considered
22     medically necessary by the woman's health care provider for
23     women under 40 years of age and having a family history of
24     breast cancer, prior personal history of breast cancer,

 

 

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1     positive genetic testing, or other risk factors.
2         (4) A comprehensive ultrasound screening of an entire
3     breast or breasts if a mammogram demonstrates
4     heterogeneous or dense breast tissue, when medically
5     necessary as determined by a physician licensed to practice
6     medicine in all of its branches.
7     These benefits shall be at least as favorable as for other
8 radiological examinations and subject to the same dollar
9 limits, deductibles, and co-insurance factors. For purposes of
10 this Section, "low-dose mammography" means the x-ray
11 examination of the breast using equipment dedicated
12 specifically for mammography, including the x-ray tube,
13 filter, compression device, and image receptor, with radiation
14 exposure delivery of less than 1 rad per breast for 2 views of
15 an average size breast.
16     (b) No contract or evidence of coverage issued by a health
17 maintenance organization that provides for the surgical
18 procedure known as a mastectomy shall be issued, amended,
19 delivered, or renewed in this State on or after the effective
20 date of this amendatory Act of the 92nd General Assembly unless
21 that coverage also provides for prosthetic devices or
22 reconstructive surgery incident to the mastectomy, providing
23 that the mastectomy is performed after the effective date of
24 this amendatory Act. Coverage for breast reconstruction in
25 connection with a mastectomy shall include:
26         (1) reconstruction of the breast upon which the

 

 

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

 

 

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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 (Source: P.A. 94-121, eff. 7-6-05.)
 
5     Section 99. Effective date. This Act takes effect upon
6 becoming law.".