Illinois Compiled Statutes
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215 ILCS 125/4-6.1
(215 ILCS 125/4-6.1)
(from Ch. 111 1/2, par. 1408.7)
(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
(2) An annual mammogram for women 40 years of age or
(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 and MRI 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.
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. The term also includes digital mammography and includes breast tomosynthesis. As used in this Section, the term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.
If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.
(a-5) Coverage as described in subsection (a) shall be provided at no cost to the enrollee and shall not be applied to an annual or lifetime maximum benefit.
(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
(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
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
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.
(c) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the effective date of P.A. 99-407); 99-588, eff. 7-20-16; 100-395, eff. 1-1-18