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92_SB0866enr SB866 Enrolled LRB9201220JSpcA 1 AN ACT concerning insurance coverage relating to 2 mastectomies and mammograms. 3 Be it enacted by the People of the State of Illinois, 4 represented in the General Assembly: 5 Section 5. The Illinois Insurance Code is amended by 6 changing Section 356g as follows: 7 (215 ILCS 5/356g) (from Ch. 73, par. 968g) 8 Sec. 356g. Mammograms; mastectomies. 9 (a) Every insurer shall provide in each group or 10 individual policy, contract, or certificate of insurance 11 issued or renewed for persons who are residents of this 12 State, coverage for screening by low-dose mammography for all 13 women 35 years of age or older for the presence of occult 14 breast cancer within the provisions of the policy, contract, 15 or certificate. The coverage shall be as follows: 16 (1) A baseline mammogram for women 35 to 39 years 17 of age. 18 (2) An annual mammogram for women 40 years of age 19 or older. 20 These benefits shall be at least as favorable as for 21 other radiological examinations and subject to the same 22 dollar limits, deductibles, and co-insurance factors. For 23 purposes of this Section, "low-dose mammography" means the 24 x-ray examination of the breast using equipment dedicated 25 specifically for mammography, including the x-ray tube, 26 filter, compression device, and image receptor, with 27 radiation exposure delivery of less than 1 rad per breast for 28 2 views of an average size breast. 29 (b) No policy of accident or health insurance that 30 provides for the surgical procedure known as a mastectomy 31 shall be issued, amended, delivered, or renewed in this State SB866 Enrolled -2- LRB9201220JSpcA 1on or after July 1, 1981,unless that coverageisalso 2 providesofferedfor prosthetic devices or reconstructive 3 surgery incident to the mastectomy, providing that the4mastectomy is performed after July 1, 1981. Coverage for 5 breast reconstruction in connection with a mastectomy shall 6 include: 7 (1) reconstruction of the breast upon which the 8 mastectomy has been performed; 9 (2) surgery and reconstruction of the other breast 10 to produce a symmetrical appearance; and 11 (3) prostheses and treatment for physical 12 complications at all stages of mastectomy, including 13 lymphedemas. 14 Care shall be determined in consultation with the attending 15 physician and the patient. The offered coverage for 16 prosthetic devices and reconstructive surgery shall be 17 subject to the deductible and coinsurance conditions applied 18 to the mastectomy, and all other terms and conditions 19 applicable to other benefits. When a mastectomy is performed 20 and there is no evidence of malignancy then the offered 21 coverage may be limited to the provision of prosthetic 22 devices and reconstructive surgery to within 2 years after 23 the date of the mastectomy. As used in this Section, 24 "mastectomy" means the removal of all or part of the breast 25 for medically necessary reasons, as determined by a licensed 26 physician. 27 Written notice of the availability of coverage under this 28 Section shall be delivered to the insured upon enrollment and 29 annually thereafter. An insurer may not deny to an insured 30 eligibility, or continued eligibility, to enroll or to renew 31 coverage under the terms of the plan solely for the purpose 32 of avoiding the requirements of this Section. An insurer may 33 not penalize or reduce or limit the reimbursement of an 34 attending provider or provide incentives (monetary or SB866 Enrolled -3- LRB9201220JSpcA 1 otherwise) to an attending provider to induce the provider to 2 provide care to an insured in a manner inconsistent with this 3 Section. 4 (Source: P.A. 90-7, eff. 6-10-97.) 5 Section 10. The Health Maintenance Organization Act is 6 amended by changing Section 4-6.1 as follows: 7 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7) 8 Sec. 4-6.1. Mammograms; mastectomies. 9 (a) Every contract or evidence of coverage issued by a 10 Health Maintenance Organization for persons who are residents 11 of this State shall contain coverage for screening by 12 low-dose mammography for all women 35 years of age or older 13 for the presence of occult breast cancer. The coverage shall 14 be as follows: 15 (1) A baseline mammogram for women 35 to 39 years 16 of age. 17 (2) An annual mammogram for women 40 years of age 18 or older. 19 These benefits shall be at least as favorable as for 20 other radiological examinations and subject to the same 21 dollar limits, deductibles, and co-insurance factors. For 22 purposes of this Section, "low-dose mammography" means the 23 x-ray examination of the breast using equipment dedicated 24 specifically for mammography, including the x-ray tube, 25 filter, compression device, and image receptor, with 26 radiation exposure delivery of less than 1 rad per breast for 27 2 views of an average size breast. 28 (b) No contract or evidence of coverage issued by a 29 health maintenance organization that provides for the 30 surgical procedure known as a mastectomy shall be issued, 31 amended, delivered, or renewed in this State on or after the 32 effective date of this amendatory Act of the 92nd General SB866 Enrolled -4- LRB9201220JSpcA 1 Assembly unless that coverage also provides for prosthetic 2 devices or reconstructive surgery incident to the mastectomy, 3 providing that the mastectomy is performed after the 4 effective date of this amendatory Act. Coverage for breast 5 reconstruction in connection 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 9 to 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 15 prosthetic devices and reconstructive surgery shall be 16 subject to the deductible and coinsurance conditions applied 17 to the mastectomy and all other terms and conditions 18 applicable to other benefits. When a mastectomy is performed 19 and there is no evidence of malignancy, then the offered 20 coverage may be limited to the provision of prosthetic 21 devices and reconstructive surgery to within 2 years after 22 the date of the mastectomy. As used in this Section, 23 "mastectomy" means the removal of all or part of the breast 24 for medically necessary reasons, as determined by a licensed 25 physician. 26 Written notice of the availability of coverage under this 27 Section shall be delivered to the enrollee upon enrollment 28 and annually thereafter. A health maintenance organization 29 may not deny to an enrollee eligibility, or continued 30 eligibility, to enroll or to renew coverage under the terms 31 of the plan solely for the purpose of avoiding the 32 requirements of this Section. A health maintenance 33 organization may not penalize or reduce or limit the 34 reimbursement of an attending provider or provide incentives SB866 Enrolled -5- LRB9201220JSpcA 1 (monetary or otherwise) to an attending provider to induce 2 the provider to provide care to an insured in a manner 3 inconsistent with this Section. 4 (Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.) 5 Section 99. Effective date. This Act takes effect upon 6 becoming law.