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90_HB2456
215 ILCS 5/356g from Ch. 73, par. 968g
215 ILCS 125/4-6.1 from Ch. 111 1/2, par. 1408.7
215 ILCS 130/3009 from Ch. 73, par. 1503-9
215 ILCS 165/10 from Ch. 32, par. 604
Amends the Illinois Insurance Code, the Health
Maintenance Organization Act, the Limited Health Service
Organization Act, and the Voluntary Health Services Plans
Act. Provides that coverage under those Acts shall include
coverage for a mastectomy and reconstructive breast surgery
performed after a mastectomy. Effective immediately.
LRB9008442JSmg
LRB9008442JSmg
1 AN ACT concerning reconstructive surgery of the breast,
2 amending named Acts.
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. Mammogram; mastectomy.
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
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1 on or after July 1, 1981, unless coverage is also offered for
2 prosthetic devices or reconstructive surgery incident to the
3 mastectomy, providing that the mastectomy is performed after
4 July 1, 1981. Coverage shall include all stages of
5 reconstruction of the breast on which a partial or total
6 mastectomy has been performed. The coverage shall also
7 include coverage for all stages and revisions of
8 reconstructive breast surgery performed on a nondiseased
9 breast to establish symmetry in the manner determined by the
10 attending physician and the patient to be appropriate after
11 reconstructive surgery on a diseased breast is performed.
12 The offered coverage for prosthetic devices and
13 reconstructive surgery shall be subject to the deductible and
14 coinsurance conditions applied to the mastectomy, and all
15 other terms and conditions applicable to other benefits.
16 When a mastectomy is performed and there is no evidence of
17 malignancy then the offered coverage may be limited to the
18 provision of prosthetic devices and reconstructive surgery to
19 within 2 years after the date of the mastectomy. As used in
20 this Section, "mastectomy" means the removal of all or part
21 of the breast for medically necessary reasons, as determined
22 by a licensed physician.
23 (Source: P.A. 90-7, eff. 6-10-97.)
24 Section 10. The Health Maintenance Organization Act is
25 amended by changing Section 4-6.1 as follows:
26 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
27 Sec. 4-6.1. Mammogram; mastectomy.
28 (a) Every contract or evidence of coverage issued by a
29 Health Maintenance Organization for persons who are residents
30 of this State shall contain coverage for screening by
31 low-dose mammography for all women 35 years of age or older
32 for the presence of occult breast cancer. The coverage shall
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1 be as follows:
2 (1) A baseline mammogram for women 35 to 39 years
3 of age.
4 (2) An annual mammogram for women 40 years of age
5 or older.
6 These benefits shall be at least as favorable as for
7 other radiological examinations and subject to the same
8 dollar limits, deductibles, and co-insurance factors. For
9 purposes of this Section, "low-dose mammography" means the
10 x-ray examination of the breast using equipment dedicated
11 specifically for mammography, including the x-ray tube,
12 filter, compression device, and image receptor, with
13 radiation exposure delivery of less than 1 rad per breast for
14 2 views of an average size breast.
15 (b) A contract or evidence of coverage amended, issued,
16 delivered, or renewed for persons who are residents of this
17 State shall provide coverage for all stages of reconstruction
18 of a breast on which a partial or total mastectomy has been
19 performed. The coverage shall also include coverage for all
20 stages and revisions of reconstructive breast surgery
21 performed on a nondiseased breast to establish symmetry in
22 the manner determined by the attending physician and patient
23 to be appropriate after reconstructive surgery on a diseased
24 breast is performed. The offered coverage shall be subject
25 to the deductible and copayment conditions applied to similar
26 surgical services covered under the contract or evidence of
27 coverage. When a mastectomy is performed and there is no
28 evidence of malignancy then the coverage may be limited to
29 the provision or prosthetic devices and reconstructive
30 surgery provided within 2 years after the date of the
31 mastectomy.
32 (Source: P.A. 90-7, eff. 6-10-97; revised 7-29-97.)
33 Section 15. The Limited Health Service Organization Act
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1 is amended by changing Section 3009 as follows:
2 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9)
3 Sec. 3009. Point-of-service limited health service
4 contracts.
5 (a) An LHSO that offers a POS contract:
6 (1) shall include as in-plan covered services all
7 services required by law to be provided by an LHSO;
8 (2) shall provide incentives, which shall include
9 financial incentives, for enrollees to use in-plan
10 covered services;
11 (3) shall not offer services out-of-plan without
12 providing those services on an in-plan basis;
13 (4) may limit or exclude specific types of services
14 from coverage when obtained out-of-plan;
15 (5) may include annual out-of-pocket limits and
16 lifetime maximum benefits allowances for out-of-plan
17 services that are separate from any limits or allowances
18 applied to in-plan services;
19 (6) shall include an annual maximum benefit
20 allowance not to exceed $2,500 per year that is separate
21 from any limits or allowances applied to in-plan
22 services;
23 (7) may limit the groups to which a POS product is
24 offered, however, if a POS product is offered to a group,
25 then it must be offered to all eligible members of that
26 group, when an LHSO provider is available;
27 (8) shall not consider emergency services,
28 authorized referral services, or non-routine services
29 obtained out of the service area to be POS services; and
30 (9) may treat as out-of-plan services those
31 services that an enrollee obtains from a participating
32 provider, but for which the proper authorization was not
33 given by the LHSO.
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1 (b) An LHSO offering a POS contract shall be subject to
2 the following limitations:
3 (1) The LHSO shall not expend in any calendar
4 quarter more than 20% of its total limited health
5 services expenditures for all its members for out-of-plan
6 covered services.
7 (2) If the amount specified in paragraph (1) is
8 exceeded by 2% in a quarter, the LHSO shall effect
9 compliance with paragraph (1) by the end of the following
10 quarter.
11 (3) If compliance with the amount specified in
12 paragraph (1) is not demonstrated in the LHSO's next
13 quarterly report, the LHSO may not offer the POS contract
14 to new groups or include the POS option in the renewal of
15 an existing group until compliance with the amount
16 specified in paragraph (1) is demonstrated or otherwise
17 allowed by the Director.
18 (4) Any LHSO failing, without just cause, to comply
19 with the provisions of this subsection shall be required,
20 after notice and hearing, to pay a penalty of $250 for
21 each day out of compliance, to be recovered by the
22 Director of Insurance. Any penalty recovered shall be
23 paid into the General Revenue Fund. The Director may
24 reduce the penalty if the LHSO demonstrates to the
25 Director that the imposition of the penalty would
26 constitute a financial hardship to the LHSO.
27 (c) Any LHSO that offers a POS product shall:
28 (1) File a quarterly financial statement detailing
29 compliance with the requirements of subsection (b).
30 (2) Track out-of-plan POS utilization separately
31 from in-plan or non-POS out-of-plan emergency care,
32 referral care, and urgent care out of the service area
33 utilization.
34 (3) Record out-of-plan utilization in a manner that
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1 will permit such utilization and cost reporting as the
2 Director may, by regulation, require.
3 (4) Demonstrate to the Director's satisfaction that
4 the LHSO has the fiscal, administrative, and marketing
5 capacity to control its POS enrollment, utilization, and
6 costs so as not to jeopardize the financial security of
7 the LHSO.
8 (5) Maintain the deposit required by subsection (b)
9 of Section 2006 in addition to any other deposit required
10 under this Act.
11 (d) An LHSO shall not issue a POS contract until it has
12 filed and had approved by the Director a plan to comply with
13 the provisions of this Section. The compliance plan shall at
14 a minimum include provisions demonstrating that the LHSO will
15 do all of the following:
16 (1) Design the benefit levels and conditions of
17 coverage for in-plan covered services and out-of-plan
18 covered services as required by this Article.
19 (2) Provide or arrange for the provision of
20 adequate systems to:
21 (A) process and pay claims for all out-of-plan
22 covered services;
23 (B) meet the requirements for a POS contract
24 set forth in this Section and any additional
25 requirements that may be set forth by the Director;
26 and
27 (C) generate accurate data and financial and
28 regulatory reports on a timely basis so that the
29 Department can evaluate the LHSO's experience with
30 the POS contract and monitor compliance with POS
31 contract provisions.
32 (3) Comply initially and on an ongoing basis with
33 the requirements of subsections (b) and (c).
34 (e) A limited health service organization shall comply
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1 with the provisions of Section 356g of the Illinois Insurance
2 Code.
3 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.)
4 Section 20. The Voluntary Health Services Plans Act is
5 amended by changing Section 10 as follows:
6 (215 ILCS 165/10) (from Ch. 32, par. 604)
7 Sec. 10. Application of Insurance Code provisions.
8 Health services plan corporations and all persons interested
9 therein or dealing therewith shall be subject to the
10 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
11 143, 143c, 149, 354, 355.2, 356g, 356r, 356t, 356u, 356v,
12 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and
13 paragraphs (7) and (15) of Section 367 of the Illinois
14 Insurance Code.
15 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97;
16 90-25, eff. 1-1-98; revised 10-14-97.)
17 Section 99. Effective date. This Act takes effect upon
18 becoming law.