Full Text of HB4312 101st General Assembly
HB4312 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB4312 Introduced 1/28/2020, by Rep. Avery Bourne SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/356g | from Ch. 73, par. 968g |
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Amends the Illinois Insurance Code. Makes a technical change in a Section concerning accident and health insurance coverage for mammograms and mastectomies.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 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 the presence of
occult breast cancer within | 13 | | the provisions of the policy, contract, or
certificate. The | 14 | | coverage shall be as follows:
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(1) A baseline mammogram for women 35 to 39 years of | 16 | | age.
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(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) For an individual or group policy of accident and | 2 | | health insurance or a managed care plan that is amended, | 3 | | delivered, issued, or renewed on or after the effective | 4 | | date of this amendatory Act of the 101st General Assembly, | 5 | | a comprehensive ultrasound screening and MRI of an entire | 6 | | breast or breasts if a mammogram demonstrates | 7 | | heterogeneous or dense breast tissue or when medically | 8 | | necessary as determined by a physician licensed to practice | 9 | | medicine in all of its branches. | 10 | | (5) A screening MRI when medically necessary, as | 11 | | determined by a physician licensed to practice medicine in | 12 | | all of its branches. | 13 | | (6) For an individual or group policy of accident and | 14 | | health insurance or a managed care plan that is amended, | 15 | | delivered, issued, or renewed on or after the effective | 16 | | date of this amendatory Act of the 101st General Assembly, | 17 | | a diagnostic mammogram when medically necessary, as | 18 | | determined by a physician licensed to practice medicine in | 19 | | all its branches, advanced practice registered nurse, or | 20 | | physician assistant. | 21 | | A policy subject to this subsection shall not impose a | 22 | | deductible, coinsurance, copayment, or any other cost-sharing | 23 | | requirement on the coverage provided; except that this sentence | 24 | | does not apply to coverage of diagnostic mammograms to the | 25 | | extent such coverage would disqualify a high-deductible health | 26 | | plan from eligibility for a health savings account pursuant to |
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| 1 | | Section 223 of the Internal Revenue Code (26 U.S.C. 223). | 2 | | For purposes of this Section: | 3 | | "Diagnostic
mammogram" means a mammogram obtained using | 4 | | diagnostic mammography. | 5 | | "Diagnostic
mammography" means a method of screening that | 6 | | is designed to
evaluate an abnormality in a breast, including | 7 | | an abnormality seen
or suspected on a screening mammogram or a | 8 | | subjective or objective
abnormality otherwise detected in the | 9 | | breast. | 10 | | "Low-dose mammography"
means the x-ray examination of the | 11 | | breast using equipment dedicated
specifically for mammography, | 12 | | including the x-ray tube, filter, compression
device, and image | 13 | | receptor, with radiation exposure delivery of less than
1 rad | 14 | | per breast for 2 views of an average size breast. The term also | 15 | | includes digital mammography and includes breast | 16 | | tomosynthesis. As used in this Section, the term "breast | 17 | | tomosynthesis" means a radiologic procedure that involves the | 18 | | acquisition of projection images over the stationary breast to | 19 | | produce cross-sectional digital three-dimensional images of | 20 | | the breast.
| 21 | | If, at any time, the Secretary of the United States | 22 | | Department of Health and Human Services, or its successor | 23 | | agency, promulgates rules or regulations to be published in the | 24 | | Federal Register or publishes a comment in the Federal Register | 25 | | or issues an opinion, guidance, or other action that would | 26 | | require the State, pursuant to any provision of the Patient |
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| 1 | | Protection and Affordable Care Act (Public Law 111-148), | 2 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 3 | | successor provision, to defray the cost of any coverage for | 4 | | breast tomosynthesis outlined in this subsection, then the | 5 | | requirement that an insurer cover breast tomosynthesis is | 6 | | inoperative other than any such coverage authorized under | 7 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 8 | | the State shall not assume any obligation for the cost of | 9 | | coverage for breast tomosynthesis set forth in this subsection. | 10 | | (a-5) Coverage as described by subsection (a) shall be | 11 | | provided at no cost to the insured and shall not be applied to | 12 | | an annual or lifetime maximum benefit. | 13 | | (a-10) When health care services are available through | 14 | | contracted providers and a person does not comply with plan | 15 | | provisions specific to the use of contracted providers, the | 16 | | requirements of subsection (a-5) are not applicable. When a | 17 | | person does not comply with plan provisions specific to the use | 18 | | of contracted providers, plan provisions specific to the use of | 19 | | non-contracted providers must be applied without distinction | 20 | | for coverage required by this Section and shall be at least as | 21 | | favorable as for other radiological examinations covered by the | 22 | | policy or contract. | 23 | | (b) No policy of accident or health insurance that provides | 24 | | for
the surgical procedure known as a mastectomy shall be | 25 | | issued, amended,
delivered, or renewed in this State unless
| 26 | | that coverage also provides for prosthetic devices
or |
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| 1 | | reconstructive surgery
incident to the mastectomy.
Coverage | 2 | | for breast reconstruction in connection with a mastectomy shall
| 3 | | 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 limited | 18 | | to the
provision of prosthetic devices and reconstructive | 19 | | surgery to within 2
years after the date of the mastectomy. As | 20 | | used in this Section,
"mastectomy" means the removal of all or | 21 | | part of the breast for medically
necessary reasons, as | 22 | | determined by a licensed physician.
| 23 | | Written notice of the availability of coverage under this | 24 | | Section shall be
delivered to the insured upon enrollment and | 25 | | annually thereafter. An insurer
may not deny to an insured | 26 | | eligibility, or continued eligibility, to enroll or
to renew |
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| 1 | | coverage under the terms of the plan solely for the purpose of
| 2 | | avoiding the requirements of this Section. An insurer may not | 3 | | penalize or
reduce or
limit the reimbursement of an attending | 4 | | provider or provide incentives
(monetary or otherwise) to an | 5 | | attending provider to induce the provider to
provide care to an | 6 | | insured in a manner inconsistent with this Section.
| 7 | | (c) Rulemaking authority to implement Public Act 95-1045, | 8 | | if any, is conditioned on the rules being adopted in accordance | 9 | | with all provisions of the Illinois Administrative Procedure | 10 | | Act and all rules and procedures of the Joint Committee on | 11 | | Administrative Rules; any purported rule not so adopted, for | 12 | | whatever reason, is unauthorized. | 13 | | (Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20 .)
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