SB0012 Enrolled LRB094 04124 LJB 34145 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 356g as follows:
 
6     (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7     Sec. 356g. Mammograms; mastectomies.
8     (a) Every insurer shall provide in each group or individual
9 policy, contract, or certificate of insurance issued or renewed
10 for persons who are residents of this State, coverage for
11 screening by low-dose mammography for all women 35 years of age
12 or older for the presence of occult breast cancer within the
13 provisions of the policy, contract, or certificate. The
14 coverage shall be as follows:
15         (1) A baseline mammogram for women 35 to 39 years of
16     age.
17         (2) An annual mammogram for women 40 years of age or
18     older.
19         (3) A mammogram at the age and intervals considered
20     medically necessary by the woman's health care provider for
21     women under 40 years of age and having a family history of
22     breast cancer or other risk factors.
23     These benefits shall be at least as favorable as for other
24 radiological examinations and subject to the same dollar
25 limits, deductibles, and co-insurance factors. For purposes of
26 this Section, "low-dose mammography" means the x-ray
27 examination of the breast using equipment dedicated
28 specifically for mammography, including the x-ray tube,
29 filter, compression device, and image receptor, with radiation
30 exposure delivery of less than 1 rad per breast for 2 views of
31 an average size breast.
32     (b) No policy of accident or health insurance that provides

 

 

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1 for the surgical procedure known as a mastectomy shall be
2 issued, amended, delivered, or renewed in this State unless
3 that coverage also provides for prosthetic devices or
4 reconstructive surgery incident to the mastectomy. Coverage
5 for 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 to
10     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 prosthetic
16 devices and reconstructive surgery shall be subject to the
17 deductible and coinsurance conditions applied to the
18 mastectomy, and all other terms and conditions applicable to
19 other benefits. When a mastectomy is performed and there is no
20 evidence of malignancy then the offered coverage may be limited
21 to the provision of prosthetic devices and reconstructive
22 surgery to within 2 years after the date of the mastectomy. As
23 used in this Section, "mastectomy" means the removal of all or
24 part of the breast for medically necessary reasons, as
25 determined by a licensed physician.
26     Written notice of the availability of coverage under this
27 Section shall be delivered to the insured upon enrollment and
28 annually thereafter. An insurer may not deny to an insured
29 eligibility, or continued eligibility, to enroll or to renew
30 coverage under the terms of the plan solely for the purpose of
31 avoiding the requirements of this Section. An insurer may not
32 penalize or reduce or limit the reimbursement of an attending
33 provider or provide incentives (monetary or otherwise) to an
34 attending provider to induce the provider to provide care to an
35 insured in a manner inconsistent with this Section.
36 (Source: P.A. 92-48, eff. 7-3-01.)
 

 

 

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1     Section 10. The Health Maintenance Organization Act is
2 amended by changing Section 4-6.1 as follows:
 
3     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
4     Sec. 4-6.1. Mammograms; mastectomies.
5     (a) Every contract or evidence of coverage issued by a
6 Health Maintenance Organization for persons who are residents
7 of this State shall contain coverage for screening by low-dose
8 mammography for all women 35 years of age or older for the
9 presence of occult breast cancer. The coverage shall be as
10 follows:
11         (1) A baseline mammogram for women 35 to 39 years of
12     age.
13         (2) An annual mammogram for women 40 years of age or
14     older.
15         (3) A mammogram at the age and intervals considered
16     medically necessary by the woman's health care provider for
17     women under 40 years of age and having a family history of
18     breast cancer or other risk factors.
19     These benefits shall be at least as favorable as for other
20 radiological examinations and subject to the same dollar
21 limits, deductibles, and co-insurance factors. For purposes of
22 this Section, "low-dose mammography" means the x-ray
23 examination of the breast using equipment dedicated
24 specifically for mammography, including the x-ray tube,
25 filter, compression device, and image receptor, with radiation
26 exposure delivery of less than 1 rad per breast for 2 views of
27 an average size breast.
28     (b) No contract or evidence of coverage issued by a health
29 maintenance organization that provides for the surgical
30 procedure known as a mastectomy shall be issued, amended,
31 delivered, or renewed in this State on or after the effective
32 date of this amendatory Act of the 92nd General Assembly unless
33 that coverage also provides for prosthetic devices or
34 reconstructive surgery incident to the mastectomy, providing

 

 

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1 that the mastectomy is performed after the effective date of
2 this amendatory Act. Coverage for breast reconstruction in
3 connection with a mastectomy shall include:
4         (1) reconstruction of the breast upon which the
5     mastectomy has been performed;
6         (2) surgery and reconstruction of the other breast to
7     produce a symmetrical appearance; and
8         (3) prostheses and treatment for physical
9     complications at all stages of mastectomy, including
10     lymphedemas.
11 Care shall be determined in consultation with the attending
12 physician and the patient. The offered coverage for prosthetic
13 devices and reconstructive surgery shall be subject to the
14 deductible and coinsurance conditions applied to the
15 mastectomy and all other terms and conditions applicable to
16 other benefits. When a mastectomy is performed and there is no
17 evidence of malignancy, then the offered coverage may be
18 limited to the provision of prosthetic devices and
19 reconstructive surgery to within 2 years after the date of the
20 mastectomy. As used in this Section, "mastectomy" means the
21 removal of all or part of the breast for medically necessary
22 reasons, as determined by a licensed physician.
23     Written notice of the availability of coverage under this
24 Section shall be delivered to the enrollee upon enrollment and
25 annually thereafter. A health maintenance organization may not
26 deny to an enrollee eligibility, or continued eligibility, to
27 enroll or to renew coverage under the terms of the plan solely
28 for the purpose of avoiding the requirements of this Section. A
29 health maintenance organization may not penalize or reduce or
30 limit the reimbursement of an attending provider or provide
31 incentives (monetary or otherwise) to an attending provider to
32 induce the provider to provide care to an insured in a manner
33 inconsistent with this Section.
34 (Source: P.A. 92-48, eff. 7-3-01.)
 
35     Section 99. Effective date. This Act takes effect upon

 

 

SB0012 Enrolled - 5 - LRB094 04124 LJB 34145 b

1 becoming law.