99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB0054

 

Introduced 1/15/2015, by Sen. John G. Mulroe

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356g  from Ch. 73, par. 968g
215 ILCS 125/4-6.1  from Ch. 111 1/2, par. 1408.7

    Amends the Illinois Insurance Code and the Health Maintenance Organization Act. Includes breast tomosynthesis in the definition of "low-dose mammography".


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A BILL FOR

 

SB0054LRB099 03946 MLM 23963 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing 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
9policy, contract, or certificate of insurance issued or renewed
10for persons who are residents of this State, coverage for
11screening by low-dose mammography for all women 35 years of age
12or older for the presence of occult breast cancer within the
13provisions of the policy, contract, or certificate. The
14coverage 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, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.

 

 

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1        (4) A comprehensive ultrasound screening of an entire
2    breast or breasts if a mammogram demonstrates
3    heterogeneous or dense breast tissue, when medically
4    necessary as determined by a physician licensed to practice
5    medicine in all of its branches.
6    For purposes of this Section, "low-dose mammography" means
7the x-ray examination of the breast using equipment dedicated
8specifically for mammography, including the x-ray tube,
9filter, compression device, and image receptor, with radiation
10exposure delivery of less than 1 rad per breast for 2 views of
11an average size breast. The term also includes digital
12mammography and breast tomosynthesis. As used in this Section,
13the term "breast tomosynthesis" means a radiologic procedure
14that involves the acquisition of projection images over the
15stationary breast to produce cross-sectional digital
16three-dimensional images of the breast.
17    (a-5) Coverage as described by subsection (a) shall be
18provided at no cost to the insured and shall not be applied to
19an annual or lifetime maximum benefit.
20    (a-10) When health care services are available through
21contracted providers and a person does not comply with plan
22provisions specific to the use of contracted providers, the
23requirements of subsection (a-5) are not applicable. When a
24person does not comply with plan provisions specific to the use
25of contracted providers, plan provisions specific to the use of
26non-contracted providers must be applied without distinction

 

 

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1for coverage required by this Section and shall be at least as
2favorable as for other radiological examinations covered by the
3policy or contract.
4    (b) No policy of accident or health insurance that provides
5for the surgical procedure known as a mastectomy shall be
6issued, amended, delivered, or renewed in this State unless
7that coverage also provides for prosthetic devices or
8reconstructive surgery incident to the mastectomy. Coverage
9for breast reconstruction in connection with a mastectomy shall
10include:
11        (1) reconstruction of the breast upon which the
12    mastectomy has been performed;
13        (2) surgery and reconstruction of the other breast to
14    produce a symmetrical appearance; and
15        (3) prostheses and treatment for physical
16    complications at all stages of mastectomy, including
17    lymphedemas.
18Care shall be determined in consultation with the attending
19physician and the patient. The offered coverage for prosthetic
20devices and reconstructive surgery shall be subject to the
21deductible and coinsurance conditions applied to the
22mastectomy, and all other terms and conditions applicable to
23other benefits. When a mastectomy is performed and there is no
24evidence of malignancy then the offered coverage may be limited
25to the provision of prosthetic devices and reconstructive
26surgery to within 2 years after the date of the mastectomy. As

 

 

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1used in this Section, "mastectomy" means the removal of all or
2part of the breast for medically necessary reasons, as
3determined by a licensed physician.
4    Written notice of the availability of coverage under this
5Section shall be delivered to the insured upon enrollment and
6annually thereafter. An insurer may not deny to an insured
7eligibility, or continued eligibility, to enroll or to renew
8coverage under the terms of the plan solely for the purpose of
9avoiding the requirements of this Section. An insurer may not
10penalize or reduce or limit the reimbursement of an attending
11provider or provide incentives (monetary or otherwise) to an
12attending provider to induce the provider to provide care to an
13insured in a manner inconsistent with this Section.
14    (c) Rulemaking authority to implement this amendatory Act
15of the 95th General Assembly, if any, is conditioned on the
16rules being adopted in accordance with all provisions of the
17Illinois Administrative Procedure Act and all rules and
18procedures of the Joint Committee on Administrative Rules; any
19purported rule not so adopted, for whatever reason, is
20unauthorized.
21(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
2295-1045, eff. 3-27-09.)
 
23    Section 10. The Health Maintenance Organization Act is
24amended by changing Section 4-6.1 as follows:
 

 

 

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1    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
2    Sec. 4-6.1. Mammograms; mastectomies.
3    (a) Every contract or evidence of coverage issued by a
4Health Maintenance Organization for persons who are residents
5of this State shall contain coverage for screening by low-dose
6mammography for all women 35 years of age or older for the
7presence of occult breast cancer. The coverage shall be as
8follows:
9        (1) A baseline mammogram for women 35 to 39 years of
10    age.
11        (2) An annual mammogram for women 40 years of age or
12    older.
13        (3) A mammogram at the age and intervals considered
14    medically necessary by the woman's health care provider for
15    women under 40 years of age and having a family history of
16    breast cancer, prior personal history of breast cancer,
17    positive genetic testing, or other risk factors.
18        (4) A comprehensive ultrasound screening of an entire
19    breast or breasts if a mammogram demonstrates
20    heterogeneous or dense breast tissue, when medically
21    necessary as determined by a physician licensed to practice
22    medicine in all of its branches.
23    For purposes of this Section, "low-dose mammography" means
24the x-ray examination of the breast using equipment dedicated
25specifically for mammography, including the x-ray tube,
26filter, compression device, and image receptor, with radiation

 

 

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1exposure delivery of less than 1 rad per breast for 2 views of
2an average size breast. The term also includes digital
3mammography and breast tomosynthesis. As used in this Section,
4the term "breast tomosynthesis" means a radiologic procedure
5that involves the acquisition of projection images over the
6stationary breast to produce cross-sectional digital
7three-dimensional images of the breast.
8    (a-5) Coverage as described in subsection (a) shall be
9provided at no cost to the enrollee and shall not be applied to
10an annual or lifetime maximum benefit.
11    (b) No contract or evidence of coverage issued by a health
12maintenance organization that provides for the surgical
13procedure known as a mastectomy shall be issued, amended,
14delivered, or renewed in this State on or after the effective
15date of this amendatory Act of the 92nd General Assembly unless
16that coverage also provides for prosthetic devices or
17reconstructive surgery incident to the mastectomy, providing
18that the mastectomy is performed after the effective date of
19this amendatory Act. Coverage for breast reconstruction in
20connection with a mastectomy shall include:
21        (1) reconstruction of the breast upon which the
22    mastectomy has been performed;
23        (2) surgery and reconstruction of the other breast to
24    produce a symmetrical appearance; and
25        (3) prostheses and treatment for physical
26    complications at all stages of mastectomy, including

 

 

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1    lymphedemas.
2Care shall be determined in consultation with the attending
3physician and the patient. The offered coverage for prosthetic
4devices and reconstructive surgery shall be subject to the
5deductible and coinsurance conditions applied to the
6mastectomy and all other terms and conditions applicable to
7other benefits. When a mastectomy is performed and there is no
8evidence of malignancy, then the offered coverage may be
9limited to the provision of prosthetic devices and
10reconstructive surgery to within 2 years after the date of the
11mastectomy. As used in this Section, "mastectomy" means the
12removal of all or part of the breast for medically necessary
13reasons, as determined by a licensed physician.
14    Written notice of the availability of coverage under this
15Section shall be delivered to the enrollee upon enrollment and
16annually thereafter. A health maintenance organization may not
17deny to an enrollee eligibility, or continued eligibility, to
18enroll or to renew coverage under the terms of the plan solely
19for the purpose of avoiding the requirements of this Section. A
20health maintenance organization may not penalize or reduce or
21limit the reimbursement of an attending provider or provide
22incentives (monetary or otherwise) to an attending provider to
23induce the provider to provide care to an insured in a manner
24inconsistent with this Section.
25    (c) Rulemaking authority to implement this amendatory Act
26of the 95th General Assembly, if any, is conditioned on the

 

 

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1rules being adopted in accordance with all provisions of the
2Illinois Administrative Procedure Act and all rules and
3procedures of the Joint Committee on Administrative Rules; any
4purported rule not so adopted, for whatever reason, is
5unauthorized.
6(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
795-1045, eff. 3-27-09.)