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Public Act 92-0048
SB866 Enrolled LRB9201220JSpcA
AN ACT concerning insurance coverage relating to
mastectomies and mammograms.
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.
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
on or after July 1, 1981, unless that coverage is also
provides offered for prosthetic devices or reconstructive
surgery incident to the mastectomy, providing that the
mastectomy is performed after July 1, 1981. 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. 90-7, eff. 6-10-97.)
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.
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. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)
Section 99. Effective date. This Act takes effect upon
becoming law.
Passed in the General Assembly May 01, 2001.
Approved July 03, 2001.
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