Public Act 095-0431
 
SB1365 Enrolled LRB095 04641 KBJ 24699 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Insurance Code is amended by
changing Section 356g as follows:
 
    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
    Sec. 356g. Mammograms; mastectomies.
    (a) Every insurer shall provide in each group or individual
policy, contract, or certificate of insurance issued or renewed
for persons who are residents of this State, coverage for
screening by low-dose mammography for all women 35 years of age
or older for the presence of occult breast cancer within the
provisions of the policy, contract, or certificate. The
coverage shall be as follows:
        (1) A baseline mammogram for women 35 to 39 years of
    age.
        (2) An annual mammogram for women 40 years of age or
    older.
        (3) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider for
    women under 40 years of age and having a family history of
    breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (4) A comprehensive ultrasound screening of an entire
    breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue, when medically
    necessary as determined by a physician licensed to practice
    medicine in all of its branches.
    These benefits shall be at least as favorable as for other
radiological examinations and subject to the same dollar
limits, deductibles, and co-insurance factors. For purposes of
this Section, "low-dose mammography" means the x-ray
examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube,
filter, compression device, and image receptor, with radiation
exposure delivery of less than 1 rad per breast for 2 views of
an average size breast.
    (b) No policy of accident or health insurance that provides
for the surgical procedure known as a mastectomy shall be
issued, amended, delivered, or renewed in this State unless
that coverage also provides for prosthetic devices or
reconstructive surgery incident to the mastectomy. Coverage
for breast reconstruction in connection with a mastectomy shall
include:
        (1) reconstruction of the breast upon which the
    mastectomy has been performed;
        (2) surgery and reconstruction of the other breast to
    produce a symmetrical appearance; and
        (3) prostheses and treatment for physical
    complications at all stages of mastectomy, including
    lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic
devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy, and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy then the offered coverage may be limited
to the provision of prosthetic devices and reconstructive
surgery to within 2 years after the date of the mastectomy. As
used in this Section, "mastectomy" means the removal of all or
part of the breast for medically necessary reasons, as
determined by a licensed physician.
    Written notice of the availability of coverage under this
Section shall be delivered to the insured upon enrollment and
annually thereafter. An insurer may not deny to an insured
eligibility, or continued eligibility, to enroll or to renew
coverage under the terms of the plan solely for the purpose of
avoiding the requirements of this Section. An insurer may not
penalize or reduce or limit the reimbursement of an attending
provider or provide incentives (monetary or otherwise) to an
attending provider to induce the provider to provide care to an
insured in a manner inconsistent with this Section.
(Source: P.A. 94-121, eff. 7-6-05.)
 
    Section 10. The Health Maintenance Organization Act is
amended by changing Section 4-6.1 as follows:
 
    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
    Sec. 4-6.1. Mammograms; mastectomies.
    (a) Every contract or evidence of coverage issued by a
Health Maintenance Organization for persons who are residents
of this State shall contain coverage for screening by low-dose
mammography for all women 35 years of age or older for the
presence of occult breast cancer. The coverage shall be as
follows:
        (1) A baseline mammogram for women 35 to 39 years of
    age.
        (2) An annual mammogram for women 40 years of age or
    older.
        (3) A mammogram at the age and intervals considered
    medically necessary by the woman's health care provider for
    women under 40 years of age and having a family history of
    breast cancer, prior personal history of breast cancer,
    positive genetic testing, or other risk factors.
        (4) A comprehensive ultrasound screening of an entire
    breast or breasts if a mammogram demonstrates
    heterogeneous or dense breast tissue, when medically
    necessary as determined by a physician licensed to practice
    medicine in all of its branches.
    These benefits shall be at least as favorable as for other
radiological examinations and subject to the same dollar
limits, deductibles, and co-insurance factors. For purposes of
this Section, "low-dose mammography" means the x-ray
examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube,
filter, compression device, and image receptor, with radiation
exposure delivery of less than 1 rad per breast for 2 views of
an average size breast.
    (b) No contract or evidence of coverage issued by a health
maintenance organization that provides for the surgical
procedure known as a mastectomy shall be issued, amended,
delivered, or renewed in this State on or after the effective
date of this amendatory Act of the 92nd General Assembly unless
that coverage also provides for prosthetic devices or
reconstructive surgery incident to the mastectomy, providing
that the mastectomy is performed after the effective date of
this amendatory Act. Coverage for breast reconstruction in
connection with a mastectomy shall include:
        (1) reconstruction of the breast upon which the
    mastectomy has been performed;
        (2) surgery and reconstruction of the other breast to
    produce a symmetrical appearance; and
        (3) prostheses and treatment for physical
    complications at all stages of mastectomy, including
    lymphedemas.
Care shall be determined in consultation with the attending
physician and the patient. The offered coverage for prosthetic
devices and reconstructive surgery shall be subject to the
deductible and coinsurance conditions applied to the
mastectomy and all other terms and conditions applicable to
other benefits. When a mastectomy is performed and there is no
evidence of malignancy, then the offered coverage may be
limited to the provision of prosthetic devices and
reconstructive surgery to within 2 years after the date of the
mastectomy. As used in this Section, "mastectomy" means the
removal of all or part of the breast for medically necessary
reasons, as determined by a licensed physician.
    Written notice of the availability of coverage under this
Section shall be delivered to the enrollee upon enrollment and
annually thereafter. A health maintenance organization may not
deny to an enrollee eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the plan solely
for the purpose of avoiding the requirements of this Section. A
health maintenance organization may not penalize or reduce or
limit the reimbursement of an attending provider or provide
incentives (monetary or otherwise) to an attending provider to
induce the provider to provide care to an insured in a manner
inconsistent with this Section.
(Source: P.A. 94-121, eff. 7-6-05.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.