95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
HB5192

 

Introduced , by Rep. Greg Harris

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Public Aid Code, the Illinois Insurance Code, and other Acts. Provides that on and after July 1, 2008, screening and diagnostic mammography shall be reimbursed under the medical assistance program at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography. Requires the Department of Healthcare and Family Services to take certain actions in relation to breast cancer screening and treatment, including establishment of bonus payments to mammography facilities meeting certain standards, a rate methodology for certain providers, and a performance goal for primary care providers; also requires the Department to establish a case-management or patient-navigation pilot program. Provides that a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after the effective date of this amendatory Act must provide coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer on the same terms and conditions that are generally applicable to coverage for other conditions. Provides that mandatory insurance coverage relating to mammography shall be provided at no cost to the insured and shall not be subject to an annual or lifetime maximum benefit. Makes other changes in relation to mammography coverage, and makes these changes to the Illinois Insurance Code also applicable to the State Employees Group Insurance Act of 1971, the Health Maintenance Organization Act, and other Acts. Sets forth a statement of legislative intent and provides that the bill's provisions may be referred to as the Reducing Breast Cancer Disparities Act. Effective immediately.


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FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

HB5192 LRB095 17610 DRJ 45972 b

1     AN ACT concerning health, which may be referred to as the
2 Reducing Breast Cancer Disparities Act.
 
3     Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
 
5
Article 1. Legislative Intent

 
6     Section 1-1. Legislative intent. The General Assembly
7 finds that the mortality associated with breast cancer for
8 minority women in Illinois is significantly higher compared to
9 non-minority women. This disparity has grown over the last 2
10 decades and is unacceptable. A recent New England Journal of
11 Medicine article found that even modest cost-sharing deters
12 women from getting a mammogram. The reduction was most
13 pronounced for those with lower income and less education. Many
14 other studies have found that women with lower family income
15 and those relying on public programs for healthcare access
16 mammography at a lower rate. It is, therefore, the intent of
17 this legislation to decrease health disparities as they relate
18 to breast cancer and to improve access for all women to quality
19 breast cancer screening and treatment where necessary.
 
20
Article 5. Improving State Healthcare Programs
21
With Respect To
22
Mammography And Breast Cancer Treatment

 

 

 

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1     Section 5-5. The Illinois Public Aid Code is amended by
2 changing Section 5-5 as follows:
 
3     (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
4     Sec. 5-5. Medical services. The Illinois Department, by
5 rule, shall determine the quantity and quality of and the rate
6 of reimbursement for the medical assistance for which payment
7 will be authorized, and the medical services to be provided,
8 which may include all or part of the following: (1) inpatient
9 hospital services; (2) outpatient hospital services; (3) other
10 laboratory and X-ray services; (4) skilled nursing home
11 services; (5) physicians' services whether furnished in the
12 office, the patient's home, a hospital, a skilled nursing home,
13 or elsewhere; (6) medical care, or any other type of remedial
14 care furnished by licensed practitioners; (7) home health care
15 services; (8) private duty nursing service; (9) clinic
16 services; (10) dental services, including prevention and
17 treatment of periodontal disease and dental caries disease for
18 pregnant women; (11) physical therapy and related services;
19 (12) prescribed drugs, dentures, and prosthetic devices; and
20 eyeglasses prescribed by a physician skilled in the diseases of
21 the eye, or by an optometrist, whichever the person may select;
22 (13) other diagnostic, screening, preventive, and
23 rehabilitative services; (14) transportation and such other
24 expenses as may be necessary; (15) medical treatment of sexual

 

 

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1 assault survivors, as defined in Section 1a of the Sexual
2 Assault Survivors Emergency Treatment Act, for injuries
3 sustained as a result of the sexual assault, including
4 examinations and laboratory tests to discover evidence which
5 may be used in criminal proceedings arising from the sexual
6 assault; (16) the diagnosis and treatment of sickle cell
7 anemia; and (17) any other medical care, and any other type of
8 remedial care recognized under the laws of this State, but not
9 including abortions, or induced miscarriages or premature
10 births, unless, in the opinion of a physician, such procedures
11 are necessary for the preservation of the life of the woman
12 seeking such treatment, or except an induced premature birth
13 intended to produce a live viable child and such procedure is
14 necessary for the health of the mother or her unborn child. The
15 Illinois Department, by rule, shall prohibit any physician from
16 providing medical assistance to anyone eligible therefor under
17 this Code where such physician has been found guilty of
18 performing an abortion procedure in a wilful and wanton manner
19 upon a woman who was not pregnant at the time such abortion
20 procedure was performed. The term "any other type of remedial
21 care" shall include nursing care and nursing home service for
22 persons who rely on treatment by spiritual means alone through
23 prayer for healing.
24     Notwithstanding any other provision of this Section, a
25 comprehensive tobacco use cessation program that includes
26 purchasing prescription drugs or prescription medical devices

 

 

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1 approved by the Food and Drug administration shall be covered
2 under the medical assistance program under this Article for
3 persons who are otherwise eligible for assistance under this
4 Article.
5     Notwithstanding any other provision of this Code, the
6 Illinois Department may not require, as a condition of payment
7 for any laboratory test authorized under this Article, that a
8 physician's handwritten signature appear on the laboratory
9 test order form. The Illinois Department may, however, impose
10 other appropriate requirements regarding laboratory test order
11 documentation.
12     The Department of Healthcare and Family Services shall
13 provide the following services to persons eligible for
14 assistance under this Article who are participating in
15 education, training or employment programs operated by the
16 Department of Human Services as successor to the Department of
17 Public Aid:
18         (1) dental services, which shall include but not be
19     limited to prosthodontics; and
20         (2) eyeglasses prescribed by a physician skilled in the
21     diseases of the eye, or by an optometrist, whichever the
22     person may select.
23     The Illinois Department, by rule, may distinguish and
24 classify the medical services to be provided only in accordance
25 with the classes of persons designated in Section 5-2.
26     The Department of Healthcare and Family Services must

 

 

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1 provide coverage and reimbursement for amino acid-based
2 elemental formulas, regardless of delivery method, for the
3 diagnosis and treatment of (i) eosinophilic disorders and (ii)
4 short bowel syndrome when the prescribing physician has issued
5 a written order stating that the amino acid-based elemental
6 formula is medically necessary.
7     The Illinois Department shall authorize the provision of,
8 and shall authorize payment for, screening by low-dose
9 mammography for the presence of occult breast cancer for women
10 35 years of age or older who are eligible for medical
11 assistance under this Article, as follows: a baseline mammogram
12 for women 35 to 39 years of age and an annual mammogram for
13 women 40 years of age or older. All screenings shall include a
14 physical breast exam, instruction on self-examination and
15 information regarding the frequency of self-examination and
16 its value as a preventative tool. For purposes of As used in
17 this Section, "low-dose mammography" means the x-ray
18 examination of the breast using equipment dedicated
19 specifically for mammography, including the x-ray tube,
20 filter, compression device, screens, image receptors receptor,
21 and cassettes, with an average radiation exposure delivery of
22 less than one rad mid-breast, with 2 views for each breast. The
23 term also includes digital mammography.
24     On and after July 1, 2008, screening and diagnostic
25 mammography shall be reimbursed at the same rate as the
26 Medicare program's rates, including the increased

 

 

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1 reimbursement for digital mammography.
2     The Department shall convene an expert panel including
3 representatives of hospitals, free-standing mammography
4 facilities, and doctors, including radiologists, to establish
5 quality standards. Based on these quality standards, the
6 Department shall provide for bonus payments to mammography
7 facilities meeting the standards for screening and diagnosis.
8 The bonus payments shall be at least 15% higher than the
9 Medicare rates for mammography.
10     Subject to federal approval, the Department shall
11 establish a rate methodology for mammography at federally
12 qualified health centers and other encounter-rate clinics.
13 These clinics or centers may also collaborate with other
14 hospital-based mammography facilities.
15     The Department shall establish a methodology to remind
16 women who are age-appropriate for screening mammography, but
17 who have not received a mammogram within the previous 18
18 months, of the importance and benefit of screening mammography.
19     The Department shall establish a performance goal for
20 primary care providers with respect to their female patients
21 over age 40 receiving an annual mammogram. This performance
22 goal shall be used to provide additional reimbursement in the
23 form of a quality performance bonus to primary care providers
24 who meet that goal.
25     The Department shall devise a means of case-managing or
26 patient navigation for beneficiaries diagnosed with breast

 

 

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1 cancer. This program shall initially operate as a pilot program
2 in areas of the State with the highest incidence of mortality
3 related to breast cancer. At least one pilot program site shall
4 be in the metropolitan Chicago area and at least one site shall
5 be outside the metropolitan Chicago area. An evaluation of the
6 pilot program shall be carried out measuring health outcomes
7 and cost of care for those served by the pilot program compared
8 to similarly situated patients who are not served by the pilot
9 program.
10     Any medical or health care provider shall immediately
11 recommend, to any pregnant woman who is being provided prenatal
12 services and is suspected of drug abuse or is addicted as
13 defined in the Alcoholism and Other Drug Abuse and Dependency
14 Act, referral to a local substance abuse treatment provider
15 licensed by the Department of Human Services or to a licensed
16 hospital which provides substance abuse treatment services.
17 The Department of Healthcare and Family Services shall assure
18 coverage for the cost of treatment of the drug abuse or
19 addiction for pregnant recipients in accordance with the
20 Illinois Medicaid Program in conjunction with the Department of
21 Human Services.
22     All medical providers providing medical assistance to
23 pregnant women under this Code shall receive information from
24 the Department on the availability of services under the Drug
25 Free Families with a Future or any comparable program providing
26 case management services for addicted women, including

 

 

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1 information on appropriate referrals for other social services
2 that may be needed by addicted women in addition to treatment
3 for addiction.
4     The Illinois Department, in cooperation with the
5 Departments of Human Services (as successor to the Department
6 of Alcoholism and Substance Abuse) and Public Health, through a
7 public awareness campaign, may provide information concerning
8 treatment for alcoholism and drug abuse and addiction, prenatal
9 health care, and other pertinent programs directed at reducing
10 the number of drug-affected infants born to recipients of
11 medical assistance.
12     Neither the Department of Healthcare and Family Services
13 nor the Department of Human Services shall sanction the
14 recipient solely on the basis of her substance abuse.
15     The Illinois Department shall establish such regulations
16 governing the dispensing of health services under this Article
17 as it shall deem appropriate. The Department should seek the
18 advice of formal professional advisory committees appointed by
19 the Director of the Illinois Department for the purpose of
20 providing regular advice on policy and administrative matters,
21 information dissemination and educational activities for
22 medical and health care providers, and consistency in
23 procedures to the Illinois Department.
24     The Illinois Department may develop and contract with
25 Partnerships of medical providers to arrange medical services
26 for persons eligible under Section 5-2 of this Code.

 

 

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1 Implementation of this Section may be by demonstration projects
2 in certain geographic areas. The Partnership shall be
3 represented by a sponsor organization. The Department, by rule,
4 shall develop qualifications for sponsors of Partnerships.
5 Nothing in this Section shall be construed to require that the
6 sponsor organization be a medical organization.
7     The sponsor must negotiate formal written contracts with
8 medical providers for physician services, inpatient and
9 outpatient hospital care, home health services, treatment for
10 alcoholism and substance abuse, and other services determined
11 necessary by the Illinois Department by rule for delivery by
12 Partnerships. Physician services must include prenatal and
13 obstetrical care. The Illinois Department shall reimburse
14 medical services delivered by Partnership providers to clients
15 in target areas according to provisions of this Article and the
16 Illinois Health Finance Reform Act, except that:
17         (1) Physicians participating in a Partnership and
18     providing certain services, which shall be determined by
19     the Illinois Department, to persons in areas covered by the
20     Partnership may receive an additional surcharge for such
21     services.
22         (2) The Department may elect to consider and negotiate
23     financial incentives to encourage the development of
24     Partnerships and the efficient delivery of medical care.
25         (3) Persons receiving medical services through
26     Partnerships may receive medical and case management

 

 

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1     services above the level usually offered through the
2     medical assistance program.
3     Medical providers shall be required to meet certain
4 qualifications to participate in Partnerships to ensure the
5 delivery of high quality medical services. These
6 qualifications shall be determined by rule of the Illinois
7 Department and may be higher than qualifications for
8 participation in the medical assistance program. Partnership
9 sponsors may prescribe reasonable additional qualifications
10 for participation by medical providers, only with the prior
11 written approval of the Illinois Department.
12     Nothing in this Section shall limit the free choice of
13 practitioners, hospitals, and other providers of medical
14 services by clients. In order to ensure patient freedom of
15 choice, the Illinois Department shall immediately promulgate
16 all rules and take all other necessary actions so that provided
17 services may be accessed from therapeutically certified
18 optometrists to the full extent of the Illinois Optometric
19 Practice Act of 1987 without discriminating between service
20 providers.
21     The Department shall apply for a waiver from the United
22 States Health Care Financing Administration to allow for the
23 implementation of Partnerships under this Section.
24     The Illinois Department shall require health care
25 providers to maintain records that document the medical care
26 and services provided to recipients of Medical Assistance under

 

 

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1 this Article. The Illinois Department shall require health care
2 providers to make available, when authorized by the patient, in
3 writing, the medical records in a timely fashion to other
4 health care providers who are treating or serving persons
5 eligible for Medical Assistance under this Article. All
6 dispensers of medical services shall be required to maintain
7 and retain business and professional records sufficient to
8 fully and accurately document the nature, scope, details and
9 receipt of the health care provided to persons eligible for
10 medical assistance under this Code, in accordance with
11 regulations promulgated by the Illinois Department. The rules
12 and regulations shall require that proof of the receipt of
13 prescription drugs, dentures, prosthetic devices and
14 eyeglasses by eligible persons under this Section accompany
15 each claim for reimbursement submitted by the dispenser of such
16 medical services. No such claims for reimbursement shall be
17 approved for payment by the Illinois Department without such
18 proof of receipt, unless the Illinois Department shall have put
19 into effect and shall be operating a system of post-payment
20 audit and review which shall, on a sampling basis, be deemed
21 adequate by the Illinois Department to assure that such drugs,
22 dentures, prosthetic devices and eyeglasses for which payment
23 is being made are actually being received by eligible
24 recipients. Within 90 days after the effective date of this
25 amendatory Act of 1984, the Illinois Department shall establish
26 a current list of acquisition costs for all prosthetic devices

 

 

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1 and any other items recognized as medical equipment and
2 supplies reimbursable under this Article and shall update such
3 list on a quarterly basis, except that the acquisition costs of
4 all prescription drugs shall be updated no less frequently than
5 every 30 days as required by Section 5-5.12.
6     The rules and regulations of the Illinois Department shall
7 require that a written statement including the required opinion
8 of a physician shall accompany any claim for reimbursement for
9 abortions, or induced miscarriages or premature births. This
10 statement shall indicate what procedures were used in providing
11 such medical services.
12     The Illinois Department shall require all dispensers of
13 medical services, other than an individual practitioner or
14 group of practitioners, desiring to participate in the Medical
15 Assistance program established under this Article to disclose
16 all financial, beneficial, ownership, equity, surety or other
17 interests in any and all firms, corporations, partnerships,
18 associations, business enterprises, joint ventures, agencies,
19 institutions or other legal entities providing any form of
20 health care services in this State under this Article.
21     The Illinois Department may require that all dispensers of
22 medical services desiring to participate in the medical
23 assistance program established under this Article disclose,
24 under such terms and conditions as the Illinois Department may
25 by rule establish, all inquiries from clients and attorneys
26 regarding medical bills paid by the Illinois Department, which

 

 

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1 inquiries could indicate potential existence of claims or liens
2 for the Illinois Department.
3     Enrollment of a vendor that provides non-emergency medical
4 transportation, defined by the Department by rule, shall be
5 conditional for 180 days. During that time, the Department of
6 Healthcare and Family Services may terminate the vendor's
7 eligibility to participate in the medical assistance program
8 without cause. That termination of eligibility is not subject
9 to the Department's hearing process.
10     The Illinois Department shall establish policies,
11 procedures, standards and criteria by rule for the acquisition,
12 repair and replacement of orthotic and prosthetic devices and
13 durable medical equipment. Such rules shall provide, but not be
14 limited to, the following services: (1) immediate repair or
15 replacement of such devices by recipients without medical
16 authorization; and (2) rental, lease, purchase or
17 lease-purchase of durable medical equipment in a
18 cost-effective manner, taking into consideration the
19 recipient's medical prognosis, the extent of the recipient's
20 needs, and the requirements and costs for maintaining such
21 equipment. Such rules shall enable a recipient to temporarily
22 acquire and use alternative or substitute devices or equipment
23 pending repairs or replacements of any device or equipment
24 previously authorized for such recipient by the Department.
25     The Department shall execute, relative to the nursing home
26 prescreening project, written inter-agency agreements with the

 

 

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1 Department of Human Services and the Department on Aging, to
2 effect the following: (i) intake procedures and common
3 eligibility criteria for those persons who are receiving
4 non-institutional services; and (ii) the establishment and
5 development of non-institutional services in areas of the State
6 where they are not currently available or are undeveloped.
7     The Illinois Department shall develop and operate, in
8 cooperation with other State Departments and agencies and in
9 compliance with applicable federal laws and regulations,
10 appropriate and effective systems of health care evaluation and
11 programs for monitoring of utilization of health care services
12 and facilities, as it affects persons eligible for medical
13 assistance under this Code.
14     The Illinois Department shall report annually to the
15 General Assembly, no later than the second Friday in April of
16 1979 and each year thereafter, in regard to:
17         (a) actual statistics and trends in utilization of
18     medical services by public aid recipients;
19         (b) actual statistics and trends in the provision of
20     the various medical services by medical vendors;
21         (c) current rate structures and proposed changes in
22     those rate structures for the various medical vendors; and
23         (d) efforts at utilization review and control by the
24     Illinois Department.
25     The period covered by each report shall be the 3 years
26 ending on the June 30 prior to the report. The report shall

 

 

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1 include suggested legislation for consideration by the General
2 Assembly. The filing of one copy of the report with the
3 Speaker, one copy with the Minority Leader and one copy with
4 the Clerk of the House of Representatives, one copy with the
5 President, one copy with the Minority Leader and one copy with
6 the Secretary of the Senate, one copy with the Legislative
7 Research Unit, and such additional copies with the State
8 Government Report Distribution Center for the General Assembly
9 as is required under paragraph (t) of Section 7 of the State
10 Library Act shall be deemed sufficient to comply with this
11 Section.
12 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
 
13     Section 5-10. The Counties Code is amended by changing
14 Section 5-1069 as follows:
 
15     (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
16     Sec. 5-1069. Group life, health, accident, hospital, and
17 medical insurance.
18     (a) The county board of any county may arrange to provide,
19 for the benefit of employees of the county, group life, health,
20 accident, hospital, and medical insurance, or any one or any
21 combination of those types of insurance, or the county board
22 may self-insure, for the benefit of its employees, all or a
23 portion of the employees' group life, health, accident,
24 hospital, and medical insurance, or any one or any combination

 

 

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1 of those types of insurance, including a combination of
2 self-insurance and other types of insurance authorized by this
3 Section, provided that the county board complies with all other
4 requirements of this Section. The insurance may include
5 provision for employees who rely on treatment by prayer or
6 spiritual means alone for healing in accordance with the tenets
7 and practice of a well recognized religious denomination. The
8 county board may provide for payment by the county of a portion
9 or all of the premium or charge for the insurance with the
10 employee paying the balance of the premium or charge, if any.
11 If the county board undertakes a plan under which the county
12 pays only a portion of the premium or charge, the county board
13 shall provide for withholding and deducting from the
14 compensation of those employees who consent to join the plan
15 the balance of the premium or charge for the insurance.
16     (b) If the county board does not provide for self-insurance
17 or for a plan under which the county pays a portion or all of
18 the premium or charge for a group insurance plan, the county
19 board may provide for withholding and deducting from the
20 compensation of those employees who consent thereto the total
21 premium or charge for any group life, health, accident,
22 hospital, and medical insurance.
23     (c) The county board may exercise the powers granted in
24 this Section only if it provides for self-insurance or, where
25 it makes arrangements to provide group insurance through an
26 insurance carrier, if the kinds of group insurance are obtained

 

 

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1 from an insurance company authorized to do business in the
2 State of Illinois. The county board may enact an ordinance
3 prescribing the method of operation of the insurance program.
4     (d) If a county, including a home rule county, is a
5 self-insurer for purposes of providing health insurance
6 coverage for its employees, the insurance coverage shall
7 include screening by low-dose mammography for all women 35
8 years of age or older for the presence of occult breast cancer
9 unless the county elects to provide mammograms itself under
10 Section 5-1069.1. The coverage shall be as 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     Those benefits shall be at least as favorable as for other
16 radiological examinations and subject to the same dollar
17 limits, deductibles, and co-insurance factors. For purposes of
18 this subsection, "low-dose mammography" means the x-ray
19 examination of the breast using equipment dedicated
20 specifically for mammography, including the x-ray tube,
21 filter, compression device, screens, and image receptors, and
22 cassettes, with an average radiation exposure delivery of less
23 than one rad mid-breast, with 2 views for each breast. The term
24 also includes digital mammography. The requirement that
25 mammograms be included in health insurance coverage as provided
26 in this subsection (d) is an exclusive power and function of

 

 

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1 the State and is a denial and limitation under Article VII,
2 Section 6, subsection (h) of the Illinois Constitution of home
3 rule county powers. A home rule county to which this subsection
4 applies must comply with every provision of this subsection.
5     (e) The term "employees" as used in this Section includes
6 elected or appointed officials but does not include temporary
7 employees.
8     (f) The county board may, by ordinance, arrange to provide
9 group life, health, accident, hospital, and medical insurance,
10 or any one or a combination of those types of insurance, under
11 this Section to retired former employees and retired former
12 elected or appointed officials of the county.
13 (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
 
14     Section 5-15. The Illinois Municipal Code is amended by
15 changing Section 10-4-2 as follows:
 
16     (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
17     Sec. 10-4-2. Group insurance.
18     (a) The corporate authorities of any municipality may
19 arrange to provide, for the benefit of employees of the
20 municipality, group life, health, accident, hospital, and
21 medical insurance, or any one or any combination of those types
22 of insurance, and may arrange to provide that insurance for the
23 benefit of the spouses or dependents of those employees. The
24 insurance may include provision for employees or other insured

 

 

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1 persons who rely on treatment by prayer or spiritual means
2 alone for healing in accordance with the tenets and practice of
3 a well recognized religious denomination. The corporate
4 authorities may provide for payment by the municipality of a
5 portion of the premium or charge for the insurance with the
6 employee paying the balance of the premium or charge. If the
7 corporate authorities undertake a plan under which the
8 municipality pays a portion of the premium or charge, the
9 corporate authorities shall provide for withholding and
10 deducting from the compensation of those municipal employees
11 who consent to join the plan the balance of the premium or
12 charge for the insurance.
13     (b) If the corporate authorities do not provide for a plan
14 under which the municipality pays a portion of the premium or
15 charge for a group insurance plan, the corporate authorities
16 may provide for withholding and deducting from the compensation
17 of those employees who consent thereto the premium or charge
18 for any group life, health, accident, hospital, and medical
19 insurance.
20     (c) The corporate authorities may exercise the powers
21 granted in this Section only if the kinds of group insurance
22 are obtained from an insurance company authorized to do
23 business in the State of Illinois, or are obtained through an
24 intergovernmental joint self-insurance pool as authorized
25 under the Intergovernmental Cooperation Act. The corporate
26 authorities may enact an ordinance prescribing the method of

 

 

HB5192 - 20 - LRB095 17610 DRJ 45972 b

1 operation of the insurance program.
2     (d) If a municipality, including a home rule municipality,
3 is a self-insurer for purposes of providing health insurance
4 coverage for its employees, the insurance coverage shall
5 include screening by low-dose mammography for all women 35
6 years of age or older for the presence of occult breast cancer
7 unless the municipality elects to provide mammograms itself
8 under Section 10-4-2.1. The coverage shall be as follows:
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     Those benefits shall be at least as favorable as for other
14 radiological examinations and subject to the same dollar
15 limits, deductibles, and co-insurance factors. For purposes of
16 this subsection, "low-dose mammography" means the x-ray
17 examination of the breast using equipment dedicated
18 specifically for mammography, including the x-ray tube,
19 filter, compression device, screens, and image receptors, and
20 cassettes, with an average radiation exposure delivery of less
21 than one rad mid-breast, with 2 views for each breast. The term
22 also includes digital mammography. The requirement that
23 mammograms be included in health insurance coverage as provided
24 in this subsection (d) is an exclusive power and function of
25 the State and is a denial and limitation under Article VII,
26 Section 6, subsection (h) of the Illinois Constitution of home

 

 

HB5192 - 21 - LRB095 17610 DRJ 45972 b

1 rule municipality powers. A home rule municipality to which
2 this subsection applies must comply with every provision of
3 this subsection.
4 (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
 
5     Section 5-20. 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. Mammograms; mastectomies.
9     (a) Every insurer shall provide in each group or individual
10 policy, contract, or certificate of insurance issued or renewed
11 for persons who are residents of this State, coverage for
12 screening by low-dose mammography for all women 35 years of age
13 or older for the presence of occult breast cancer within the
14 provisions of the policy, contract, or certificate. The
15 coverage shall be as follows:
16         (1) A baseline mammogram for women 35 to 39 years of
17     age.
18         (2) An annual mammogram for women 40 years of age or
19     older.
20         (3) A mammogram at the age and intervals considered
21     medically necessary by the woman's health care provider for
22     women under 40 years of age and having a family history of
23     breast cancer, prior personal history of breast cancer,
24     positive genetic testing, or other risk factors.

 

 

HB5192 - 22 - LRB095 17610 DRJ 45972 b

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     These benefits shall be at least as favorable as for other
7 radiological examinations and subject to the same dollar
8 limits, deductibles, and co-insurance factors. For purposes of
9 this Section, "low-dose mammography" means the x-ray
10 examination of the breast using equipment dedicated
11 specifically for mammography, including the x-ray tube,
12 filter, compression device, screens, and image receptors, and
13 cassettes, receptor, with radiation exposure delivery of less
14 than one 1 rad mid-breast, with per breast for 2 views for each
15 of an average size breast. The term also includes digital
16 mammography.
17     (b) No policy of accident or health insurance that provides
18 for the surgical procedure known as a mastectomy shall be
19 issued, amended, delivered, or renewed in this State unless
20 that coverage also provides for prosthetic devices or
21 reconstructive surgery incident to the mastectomy. Coverage
22 for breast reconstruction in connection with a mastectomy shall
23 include:
24         (1) reconstruction of the breast upon which the
25     mastectomy has been performed;
26         (2) surgery and reconstruction of the other breast to

 

 

HB5192 - 23 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 - 24 - LRB095 17610 DRJ 45972 b

1 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
2     Section 5-25. The Health Maintenance Organization Act is
3 amended by changing Section 4-6.1 as follows:
 
4     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
5     Sec. 4-6.1. Mammograms; mastectomies.
6     (a) Every contract or evidence of coverage issued by a
7 Health Maintenance Organization for persons who are residents
8 of this State shall contain coverage for screening by low-dose
9 mammography for all women 35 years of age or older for the
10 presence of occult breast cancer. The coverage shall be as
11 follows:
12         (1) A baseline mammogram for women 35 to 39 years of
13     age.
14         (2) An annual mammogram for women 40 years of age or
15     older.
16         (3) A mammogram at the age and intervals considered
17     medically necessary by the woman's health care provider for
18     women under 40 years of age and having a family history of
19     breast cancer, prior personal history of breast cancer,
20     positive genetic testing, or other risk factors.
21         (4) A comprehensive ultrasound screening of an entire
22     breast or breasts if a mammogram demonstrates
23     heterogeneous or dense breast tissue, when medically
24     necessary as determined by a physician licensed to practice

 

 

HB5192 - 25 - LRB095 17610 DRJ 45972 b

1     medicine in all of its branches.
2     These benefits shall be at least as favorable as for other
3 radiological examinations and subject to the same dollar
4 limits, deductibles, and co-insurance factors. For purposes of
5 this Section, "low-dose mammography" means the x-ray
6 examination of the breast using equipment dedicated
7 specifically for mammography, including the x-ray tube,
8 filter, compression device, screens, and image receptors, and
9 cassettes, receptor, with radiation exposure delivery of less
10 than one 1 rad mid-breast, with per breast for 2 views for each
11 of an average size breast. The term also includes digital
12 mammography.
13     (b) No contract or evidence of coverage issued by a health
14 maintenance organization that provides for the surgical
15 procedure known as a mastectomy shall be issued, amended,
16 delivered, or renewed in this State on or after the effective
17 date of this amendatory Act of the 92nd General Assembly unless
18 that coverage also provides for prosthetic devices or
19 reconstructive surgery incident to the mastectomy, providing
20 that the mastectomy is performed after the effective date of
21 this amendatory Act. Coverage for breast reconstruction in
22 connection with a mastectomy shall include:
23         (1) reconstruction of the breast upon which the
24     mastectomy has been performed;
25         (2) surgery and reconstruction of the other breast to
26     produce a symmetrical appearance; and

 

 

HB5192 - 26 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 - 27 - LRB095 17610 DRJ 45972 b

1 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
2
Article 10. Breast Cancer Patients'
3
Access To Pain Relief

 
4     Section 10-5. The Illinois Insurance Code is amended by
5 adding Section 356g.5-1 as follows:
 
6     (215 ILCS 5/356g.5-1 new)
7     Sec. 356g.5-1. Breast cancer pain medication and therapy. A
8 group or individual policy of accident and health insurance or
9 managed care plan that is amended, delivered, issued, or
10 renewed after the effective date of this amendatory Act of the
11 95th General Assembly must provide coverage for all medically
12 necessary pain medication and pain therapy related to the
13 treatment of breast cancer on the same terms and conditions
14 that are generally applicable to coverage for other conditions.
15 For purposes of this Section, "pain therapy" means pain therapy
16 that is medically based and includes reasonably defined goals,
17 including, but not limited to, stabilizing or reducing pain,
18 with periodic evaluations of the efficacy of the pain therapy
19 against these goals. The provisions of this Section do not
20 apply to short-term travel, accident-only, limited, or
21 specified-disease policies, or to policies or contracts
22 designed for issuance to persons eligible for coverage under
23 Title XVIII of the Social Security Act, known as Medicare, or

 

 

HB5192 - 28 - LRB095 17610 DRJ 45972 b

1 any other similar coverage under State or federal governmental
2 plans.
 
3     Section 10-10. The State Employees Group Insurance Act of
4 1971 is amended by changing Section 6.11 as follows:
 
5     (5 ILCS 375/6.11)
6     Sec. 6.11. Required health benefits; Illinois Insurance
7 Code requirements. The program of health benefits shall provide
8 the post-mastectomy care benefits required to be covered by a
9 policy of accident and health insurance under Section 356t of
10 the Illinois Insurance Code. The program of health benefits
11 shall provide the coverage required under Sections 356g.5,
12 356g.5-1, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9,
13 and 356z.10 356z.9 of the Illinois Insurance Code. The program
14 of health benefits must comply with Section 155.37 of the
15 Illinois Insurance Code.
16 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
17 95-520, eff. 8-28-07; revised 12-4-07.)
 
18     Section 10-15. The Counties Code is amended by changing
19 Section 5-1069.3 as follows:
 
20     (55 ILCS 5/5-1069.3)
21     Sec. 5-1069.3. Required health benefits. If a county,
22 including a home rule county, is a self-insurer for purposes of

 

 

HB5192 - 29 - LRB095 17610 DRJ 45972 b

1 providing health insurance coverage for its employees, the
2 coverage shall include coverage for the post-mastectomy care
3 benefits required to be covered by a policy of accident and
4 health insurance under Section 356t and the coverage required
5 under Sections 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, and
6 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
7 requirement that health benefits be covered as provided in this
8 Section is an exclusive power and function of the State and is
9 a denial and limitation under Article VII, Section 6,
10 subsection (h) of the Illinois Constitution. A home rule county
11 to which this Section applies must comply with every provision
12 of this Section.
13 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
14 95-520, eff. 8-28-07; revised 12-4-07.)
 
15     Section 10-20. The Illinois Municipal Code is amended by
16 changing Section 10-4-2.3 as follows:
 
17     (65 ILCS 5/10-4-2.3)
18     Sec. 10-4-2.3. Required health benefits. If a
19 municipality, including a home rule municipality, is a
20 self-insurer for purposes of providing health insurance
21 coverage for its employees, the coverage shall include coverage
22 for the post-mastectomy care benefits required to be covered by
23 a policy of accident and health insurance under Section 356t
24 and the coverage required under Sections 356g.5, 356g.5-1,

 

 

HB5192 - 30 - LRB095 17610 DRJ 45972 b

1 356u, 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the
2 Illinois Insurance Code. The requirement that health benefits
3 be covered as provided in this is an exclusive power and
4 function of the State and is a denial and limitation under
5 Article VII, Section 6, subsection (h) of the Illinois
6 Constitution. A home rule municipality to which this Section
7 applies must comply with every provision of this Section.
8 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
9 95-520, eff. 8-28-07; revised 12-4-07.)
 
10     Section 10-25. The School Code is amended by changing
11 Section 10-22.3f as follows:
 
12     (105 ILCS 5/10-22.3f)
13     Sec. 10-22.3f. Required health benefits. Insurance
14 protection and benefits for employees shall provide the
15 post-mastectomy care benefits required to be covered by a
16 policy of accident and health insurance under Section 356t and
17 the coverage required under Sections 356g.5, 356g.5-1, 356u,
18 356w, 356x, 356z.6, and 356z.9 of the Illinois Insurance Code.
19 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
20 revised 12-4-07.)
 
21     Section 10-30. The Health Maintenance Organization Act is
22 amended by changing Section 5-3 as follows:
 

 

 

HB5192 - 31 - LRB095 17610 DRJ 45972 b

1     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
2     Sec. 5-3. Insurance Code provisions.
3     (a) Health Maintenance Organizations shall be subject to
4 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
5 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
6 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
7 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
8 356z.10 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
9 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
10 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
11 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
12 XXV, and XXVI of the Illinois Insurance Code.
13     (b) For purposes of the Illinois Insurance Code, except for
14 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health
15 Maintenance Organizations in the following categories are
16 deemed to be "domestic companies":
17         (1) a corporation authorized under the Dental Service
18     Plan Act or the Voluntary Health Services Plans Act;
19         (2) a corporation organized under the laws of this
20     State; or
21         (3) a corporation organized under the laws of another
22     state, 30% or more of the enrollees of which are residents
23     of this State, except a corporation subject to
24     substantially the same requirements in its state of
25     organization as is a "domestic company" under Article VIII
26     1/2 of the Illinois Insurance Code.

 

 

HB5192 - 32 - LRB095 17610 DRJ 45972 b

1     (c) In considering the merger, consolidation, or other
2 acquisition of control of a Health Maintenance Organization
3 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
4         (1) the Director shall give primary consideration to
5     the continuation of benefits to enrollees and the financial
6     conditions of the acquired Health Maintenance Organization
7     after the merger, consolidation, or other acquisition of
8     control takes effect;
9         (2)(i) the criteria specified in subsection (1)(b) of
10     Section 131.8 of the Illinois Insurance Code shall not
11     apply and (ii) the Director, in making his determination
12     with respect to the merger, consolidation, or other
13     acquisition of control, need not take into account the
14     effect on competition of the merger, consolidation, or
15     other acquisition of control;
16         (3) the Director shall have the power to require the
17     following information:
18             (A) certification by an independent actuary of the
19         adequacy of the reserves of the Health Maintenance
20         Organization sought to be acquired;
21             (B) pro forma financial statements reflecting the
22         combined balance sheets of the acquiring company and
23         the Health Maintenance Organization sought to be
24         acquired as of the end of the preceding year and as of
25         a date 90 days prior to the acquisition, as well as pro
26         forma financial statements reflecting projected

 

 

HB5192 - 33 - LRB095 17610 DRJ 45972 b

1         combined operation for a period of 2 years;
2             (C) a pro forma business plan detailing an
3         acquiring party's plans with respect to the operation
4         of the Health Maintenance Organization sought to be
5         acquired for a period of not less than 3 years; and
6             (D) such other information as the Director shall
7         require.
8     (d) The provisions of Article VIII 1/2 of the Illinois
9 Insurance Code and this Section 5-3 shall apply to the sale by
10 any health maintenance organization of greater than 10% of its
11 enrollee population (including without limitation the health
12 maintenance organization's right, title, and interest in and to
13 its health care certificates).
14     (e) In considering any management contract or service
15 agreement subject to Section 141.1 of the Illinois Insurance
16 Code, the Director (i) shall, in addition to the criteria
17 specified in Section 141.2 of the Illinois Insurance Code, take
18 into account the effect of the management contract or service
19 agreement on the continuation of benefits to enrollees and the
20 financial condition of the health maintenance organization to
21 be managed or serviced, and (ii) need not take into account the
22 effect of the management contract or service agreement on
23 competition.
24     (f) Except for small employer groups as defined in the
25 Small Employer Rating, Renewability and Portability Health
26 Insurance Act and except for medicare supplement policies as

 

 

HB5192 - 34 - LRB095 17610 DRJ 45972 b

1 defined in Section 363 of the Illinois Insurance Code, a Health
2 Maintenance Organization may by contract agree with a group or
3 other enrollment unit to effect refunds or charge additional
4 premiums under the following terms and conditions:
5         (i) the amount of, and other terms and conditions with
6     respect to, the refund or additional premium are set forth
7     in the group or enrollment unit contract agreed in advance
8     of the period for which a refund is to be paid or
9     additional premium is to be charged (which period shall not
10     be less than one year); and
11         (ii) the amount of the refund or additional premium
12     shall not exceed 20% of the Health Maintenance
13     Organization's profitable or unprofitable experience with
14     respect to the group or other enrollment unit for the
15     period (and, for purposes of a refund or additional
16     premium, the profitable or unprofitable experience shall
17     be calculated taking into account a pro rata share of the
18     Health Maintenance Organization's administrative and
19     marketing expenses, but shall not include any refund to be
20     made or additional premium to be paid pursuant to this
21     subsection (f)). The Health Maintenance Organization and
22     the group or enrollment unit may agree that the profitable
23     or unprofitable experience may be calculated taking into
24     account the refund period and the immediately preceding 2
25     plan years.
26     The Health Maintenance Organization shall include a

 

 

HB5192 - 35 - LRB095 17610 DRJ 45972 b

1 statement in the evidence of coverage issued to each enrollee
2 describing the possibility of a refund or additional premium,
3 and upon request of any group or enrollment unit, provide to
4 the group or enrollment unit a description of the method used
5 to calculate (1) the Health Maintenance Organization's
6 profitable experience with respect to the group or enrollment
7 unit and the resulting refund to the group or enrollment unit
8 or (2) the Health Maintenance Organization's unprofitable
9 experience with respect to the group or enrollment unit and the
10 resulting additional premium to be paid by the group or
11 enrollment unit.
12     In no event shall the Illinois Health Maintenance
13 Organization Guaranty Association be liable to pay any
14 contractual obligation of an insolvent organization to pay any
15 refund authorized under this Section.
16 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
17 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
18     Section 10-35. The Voluntary Health Services Plans Act is
19 amended by changing Section 10 as follows:
 
20     (215 ILCS 165/10)  (from Ch. 32, par. 604)
21     Sec. 10. Application of Insurance Code provisions. Health
22 services plan corporations and all persons interested therein
23 or dealing therewith shall be subject to the provisions of
24 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,

 

 

HB5192 - 36 - LRB095 17610 DRJ 45972 b

1 149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u,
2 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
3 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
4 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
5 and (15) of Section 367 of the Illinois Insurance Code.
6 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
7 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
8 8-28-07; revised 12-5-07.)
 
9
Article 15. Reducing Financial Barriers To Mammography

 
10     Section 15-5. The Illinois Insurance Code is amended by
11 changing Section 356g as follows:
 
12     (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
13     Sec. 356g. Mammograms; mastectomies.
14     (a) Every insurer shall provide in each group or individual
15 policy, contract, or certificate of insurance issued or renewed
16 for persons who are residents of this State, coverage for
17 screening by low-dose mammography for all women 35 years of age
18 or older for the presence of occult breast cancer within the
19 provisions of the policy, contract, or certificate. The
20 coverage shall be as follows:
21         (1) A baseline mammogram for women 35 to 39 years of
22     age.
23         (2) An annual mammogram for women 40 years of age or

 

 

HB5192 - 37 - LRB095 17610 DRJ 45972 b

1     older.
2         (3) A mammogram at the age and intervals considered
3     medically necessary by the woman's health care provider for
4     women under 40 years of age and having a family history of
5     breast cancer, prior personal history of breast cancer,
6     positive genetic testing, or other risk factors.
7         (4) A comprehensive ultrasound screening of an entire
8     breast or breasts if a mammogram demonstrates
9     heterogeneous or dense breast tissue, when medically
10     necessary as determined by a physician licensed to practice
11     medicine in all of its branches.
12     These benefits shall be at least as favorable as for other
13 radiological examinations and subject to the same dollar
14 limits, deductibles, and co-insurance factors. For purposes of
15 this Section, "low-dose mammography" means the x-ray
16 examination of the breast using equipment dedicated
17 specifically for mammography, including the x-ray tube,
18 filter, compression device, and image receptor, with radiation
19 exposure delivery of less than 1 rad per breast for 2 views of
20 an average size breast.
21     (a-5) Coverage as described by subsection (a) shall be
22 provided at no cost to the insured and shall not be subject to
23 an annual or lifetime maximum benefit.
24     (a-10) When health care services are available through
25 contracted providers and a person does not comply with plan
26 provisions specific to the use of contracted providers, the

 

 

HB5192 - 38 - LRB095 17610 DRJ 45972 b

1 requirements of subsection (a-5) are not applicable. When a
2 person does not comply with plan provisions specific to the use
3 of contracted providers, plan provisions specific to the use of
4 non-contracted providers must be applied without distinction
5 for coverage required by this Section and shall be at least as
6 favorable as for other radiological examinations covered by the
7 policy or contract.
8     (b) No policy of accident or health insurance that provides
9 for the surgical procedure known as a mastectomy shall be
10 issued, amended, delivered, or renewed in this State unless
11 that coverage also provides for prosthetic devices or
12 reconstructive surgery incident to the mastectomy. Coverage
13 for breast reconstruction in connection with a mastectomy shall
14 include:
15         (1) reconstruction of the breast upon which the
16     mastectomy has been performed;
17         (2) surgery and reconstruction of the other breast to
18     produce a symmetrical appearance; and
19         (3) prostheses and treatment for physical
20     complications at all stages of mastectomy, including
21     lymphedemas.
22 Care shall be determined in consultation with the attending
23 physician and the patient. The offered coverage for prosthetic
24 devices and reconstructive surgery shall be subject to the
25 deductible and coinsurance conditions applied to the
26 mastectomy, and all other terms and conditions applicable to

 

 

HB5192 - 39 - LRB095 17610 DRJ 45972 b

1 other benefits. When a mastectomy is performed and there is no
2 evidence of malignancy then the offered coverage may be limited
3 to the provision of prosthetic devices and reconstructive
4 surgery to within 2 years after the date of the mastectomy. As
5 used in this Section, "mastectomy" means the removal of all or
6 part of the breast for medically necessary reasons, as
7 determined by a licensed physician.
8     Written notice of the availability of coverage under this
9 Section shall be delivered to the insured upon enrollment and
10 annually thereafter. An insurer may not deny to an insured
11 eligibility, or continued eligibility, to enroll or to renew
12 coverage under the terms of the plan solely for the purpose of
13 avoiding the requirements of this Section. An insurer may not
14 penalize or reduce or limit the reimbursement of an attending
15 provider or provide incentives (monetary or otherwise) to an
16 attending provider to induce the provider to provide care to an
17 insured in a manner inconsistent with this Section.
18 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
19     Section 15-10. The State Employees Group Insurance Act of
20 1971 is amended by changing Section 6.11 as follows:
 
21     (5 ILCS 375/6.11)
22     Sec. 6.11. Required health benefits; Illinois Insurance
23 Code requirements. The program of health benefits shall provide
24 the post-mastectomy care benefits required to be covered by a

 

 

HB5192 - 40 - LRB095 17610 DRJ 45972 b

1 policy of accident and health insurance under Section 356t of
2 the Illinois Insurance Code. The program of health benefits
3 shall provide the coverage required under Sections 356g,
4 356g.5, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9,
5 and 356z.10 356z.9 of the Illinois Insurance Code. The program
6 of health benefits must comply with Section 155.37 of the
7 Illinois Insurance Code.
8 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
9 95-520, eff. 8-28-07; revised 12-4-07.)
 
10     Section 15-15. The Counties Code is amended by changing
11 Sections 5-1069 and 5-1069.3 as follows:
 
12     (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
13     Sec. 5-1069. Group life, health, accident, hospital, and
14 medical insurance.
15     (a) The county board of any county may arrange to provide,
16 for the benefit of employees of the county, group life, health,
17 accident, hospital, and medical insurance, or any one or any
18 combination of those types of insurance, or the county board
19 may self-insure, for the benefit of its employees, all or a
20 portion of the employees' group life, health, accident,
21 hospital, and medical insurance, or any one or any combination
22 of those types of insurance, including a combination of
23 self-insurance and other types of insurance authorized by this
24 Section, provided that the county board complies with all other

 

 

HB5192 - 41 - LRB095 17610 DRJ 45972 b

1 requirements of this Section. The insurance may include
2 provision for employees who rely on treatment by prayer or
3 spiritual means alone for healing in accordance with the tenets
4 and practice of a well recognized religious denomination. The
5 county board may provide for payment by the county of a portion
6 or all of the premium or charge for the insurance with the
7 employee paying the balance of the premium or charge, if any.
8 If the county board undertakes a plan under which the county
9 pays only a portion of the premium or charge, the county board
10 shall provide for withholding and deducting from the
11 compensation of those employees who consent to join the plan
12 the balance of the premium or charge for the insurance.
13     (b) If the county board does not provide for self-insurance
14 or for a plan under which the county pays a portion or all of
15 the premium or charge for a group insurance plan, the county
16 board may provide for withholding and deducting from the
17 compensation of those employees who consent thereto the total
18 premium or charge for any group life, health, accident,
19 hospital, and medical insurance.
20     (c) The county board may exercise the powers granted in
21 this Section only if it provides for self-insurance or, where
22 it makes arrangements to provide group insurance through an
23 insurance carrier, if the kinds of group insurance are obtained
24 from an insurance company authorized to do business in the
25 State of Illinois. The county board may enact an ordinance
26 prescribing the method of operation of the insurance program.

 

 

HB5192 - 42 - LRB095 17610 DRJ 45972 b

1     (d) If a county, including a home rule county, is a
2 self-insurer for purposes of providing health insurance
3 coverage for its employees, the insurance coverage shall
4 include screening by low-dose mammography for all women 35
5 years of age or older for the presence of occult breast cancer
6 unless the county elects to provide mammograms itself under
7 Section 5-1069.1. The coverage shall be as follows:
8         (1) A baseline mammogram for women 35 to 39 years of
9     age.
10         (2) An annual mammogram for women 40 years of age or
11     older.
12     Those benefits shall be at least as favorable as for other
13 radiological examinations and subject to the same dollar
14 limits, deductibles, and co-insurance factors. For purposes of
15 this subsection, "low-dose mammography" means the x-ray
16 examination of the breast using equipment dedicated
17 specifically for mammography, including the x-ray tube,
18 filter, compression device, screens, and image receptors, with
19 an average radiation exposure delivery of less than one rad
20 mid-breast, with 2 views for each breast. The requirement that
21 mammograms be included in health insurance coverage as provided
22 in this subsection (d) is an exclusive power and function of
23 the State and is a denial and limitation under Article VII,
24 Section 6, subsection (h) of the Illinois Constitution of home
25 rule county powers. A home rule county to which this subsection
26 applies must comply with every provision of this subsection.

 

 

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1     (e) The term "employees" as used in this Section includes
2 elected or appointed officials but does not include temporary
3 employees.
4     (f) The county board may, by ordinance, arrange to provide
5 group life, health, accident, hospital, and medical insurance,
6 or any one or a combination of those types of insurance, under
7 this Section to retired former employees and retired former
8 elected or appointed officials of the county.
9 (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
 
10     (55 ILCS 5/5-1069.3)
11     Sec. 5-1069.3. Required health benefits. If a county,
12 including a home rule county, is a self-insurer for purposes of
13 providing health insurance coverage for its employees, the
14 coverage shall include coverage for the post-mastectomy care
15 benefits required to be covered by a policy of accident and
16 health insurance under Section 356t and the coverage required
17 under Sections 356g, 356g.5, 356u, 356w, 356x, 356z.6, and
18 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
19 requirement that health benefits be covered as provided in this
20 Section is an exclusive power and function of the State and is
21 a denial and limitation under Article VII, Section 6,
22 subsection (h) of the Illinois Constitution. A home rule county
23 to which this Section applies must comply with every provision
24 of this Section.
25 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;

 

 

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1 95-520, eff. 8-28-07; revised 12-4-07.)
 
2     Section 15-20. The Illinois Municipal Code is amended by
3 changing Sections 10-4-2 and 10-4-2.3 as follows:
 
4     (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
5     Sec. 10-4-2. Group insurance.
6     (a) The corporate authorities of any municipality may
7 arrange to provide, for the benefit of employees of the
8 municipality, group life, health, accident, hospital, and
9 medical insurance, or any one or any combination of those types
10 of insurance, and may arrange to provide that insurance for the
11 benefit of the spouses or dependents of those employees. The
12 insurance may include provision for employees or other insured
13 persons who rely on treatment by prayer or spiritual means
14 alone for healing in accordance with the tenets and practice of
15 a well recognized religious denomination. The corporate
16 authorities may provide for payment by the municipality of a
17 portion of the premium or charge for the insurance with the
18 employee paying the balance of the premium or charge. If the
19 corporate authorities undertake a plan under which the
20 municipality pays a portion of the premium or charge, the
21 corporate authorities shall provide for withholding and
22 deducting from the compensation of those municipal employees
23 who consent to join the plan the balance of the premium or
24 charge for the insurance.

 

 

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1     (b) If the corporate authorities do not provide for a plan
2 under which the municipality pays a portion of the premium or
3 charge for a group insurance plan, the corporate authorities
4 may provide for withholding and deducting from the compensation
5 of those employees who consent thereto the premium or charge
6 for any group life, health, accident, hospital, and medical
7 insurance.
8     (c) The corporate authorities may exercise the powers
9 granted in this Section only if the kinds of group insurance
10 are obtained from an insurance company authorized to do
11 business in the State of Illinois, or are obtained through an
12 intergovernmental joint self-insurance pool as authorized
13 under the Intergovernmental Cooperation Act. The corporate
14 authorities may enact an ordinance prescribing the method of
15 operation of the insurance program.
16     (d) If a municipality, including a home rule municipality,
17 is a self-insurer for purposes of providing health insurance
18 coverage for its employees, the insurance coverage shall
19 include screening by low-dose mammography for all women 35
20 years of age or older for the presence of occult breast cancer
21 unless the municipality elects to provide mammograms itself
22 under Section 10-4-2.1. The coverage shall be as follows:
23         (1) A baseline mammogram for women 35 to 39 years of
24     age.
25         (2) An annual mammogram for women 40 years of age or
26     older.

 

 

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1     Those benefits shall be at least as favorable as for other
2 radiological examinations and subject to the same dollar
3 limits, deductibles, and co-insurance factors. For purposes of
4 this subsection, "low-dose mammography" means the x-ray
5 examination of the breast using equipment dedicated
6 specifically for mammography, including the x-ray tube,
7 filter, compression device, screens, and image receptors, with
8 an average radiation exposure delivery of less than one rad
9 mid-breast, with 2 views for each breast. The requirement that
10 mammograms be included in health insurance coverage as provided
11 in this subsection (d) is an exclusive power and function of
12 the State and is a denial and limitation under Article VII,
13 Section 6, subsection (h) of the Illinois Constitution of home
14 rule municipality powers. A home rule municipality to which
15 this subsection applies must comply with every provision of
16 this subsection.
17 (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
 
18     (65 ILCS 5/10-4-2.3)
19     Sec. 10-4-2.3. Required health benefits. If a
20 municipality, including a home rule municipality, is a
21 self-insurer for purposes of providing health insurance
22 coverage for its employees, the coverage shall include coverage
23 for the post-mastectomy care benefits required to be covered by
24 a policy of accident and health insurance under Section 356t
25 and the coverage required under Sections 356g, 356g.5, 356u,

 

 

HB5192 - 47 - LRB095 17610 DRJ 45972 b

1 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the
2 Illinois Insurance Code. The requirement that health benefits
3 be covered as provided in this is an exclusive power and
4 function of the State and is a denial and limitation under
5 Article VII, Section 6, subsection (h) of the Illinois
6 Constitution. A home rule municipality to which this Section
7 applies must comply with every provision of this Section.
8 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
9 95-520, eff. 8-28-07; revised 12-4-07.)
 
10     Section 15-25. The School Code is amended by changing
11 Section 10-22.3f as follows:
 
12     (105 ILCS 5/10-22.3f)
13     Sec. 10-22.3f. Required health benefits. Insurance
14 protection and benefits for employees shall provide the
15 post-mastectomy care benefits required to be covered by a
16 policy of accident and health insurance under Section 356t and
17 the coverage required under Sections 356g, 356g.5, 356u, 356w,
18 356x, 356z.6, and 356z.9 of the Illinois Insurance Code.
19 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
20 revised 12-4-07.)
 
21     Section 15-30. The Health Maintenance Organization Act is
22 amended by changing Section 4-6.1 as follows:
 

 

 

HB5192 - 48 - LRB095 17610 DRJ 45972 b

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
4 Health Maintenance Organization for persons who are residents
5 of this State shall contain coverage for screening by low-dose
6 mammography for all women 35 years of age or older for the
7 presence of occult breast cancer. The coverage shall be as
8 follows:
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     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

 

 

HB5192 - 49 - LRB095 17610 DRJ 45972 b

1 examination of the breast using equipment dedicated
2 specifically for mammography, including the x-ray tube,
3 filter, compression device, and image receptor, with radiation
4 exposure delivery of less than 1 rad per breast for 2 views of
5 an average size breast.
6     (a-5) Coverage as described in subsection (a) shall be
7 provided at no cost to the enrollee, shall not be subject to an
8 annual or lifetime maximum benefit, and shall be at least as
9 favorable as for other radiological examinations covered by the
10 policy or contract.
11     (b) No contract or evidence of coverage issued by a health
12 maintenance organization that provides for the surgical
13 procedure known as a mastectomy shall be issued, amended,
14 delivered, or renewed in this State on or after the effective
15 date of this amendatory Act of the 92nd General Assembly unless
16 that coverage also provides for prosthetic devices or
17 reconstructive surgery incident to the mastectomy, providing
18 that the mastectomy is performed after the effective date of
19 this amendatory Act. Coverage for breast reconstruction in
20 connection 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

 

 

HB5192 - 50 - LRB095 17610 DRJ 45972 b

1     lymphedemas.
2 Care shall be determined in consultation with the attending
3 physician and the patient. The offered coverage for prosthetic
4 devices and reconstructive surgery shall be subject to the
5 deductible and coinsurance conditions applied to the
6 mastectomy and all other terms and conditions applicable to
7 other benefits. When a mastectomy is performed and there is no
8 evidence of malignancy, then the offered coverage may be
9 limited to the provision of prosthetic devices and
10 reconstructive surgery to within 2 years after the date of the
11 mastectomy. As used in this Section, "mastectomy" means the
12 removal of all or part of the breast for medically necessary
13 reasons, as determined by a licensed physician.
14     Written notice of the availability of coverage under this
15 Section shall be delivered to the enrollee upon enrollment and
16 annually thereafter. A health maintenance organization may not
17 deny to an enrollee eligibility, or continued eligibility, to
18 enroll or to renew coverage under the terms of the plan solely
19 for the purpose of avoiding the requirements of this Section. A
20 health maintenance organization may not penalize or reduce or
21 limit the reimbursement of an attending provider or provide
22 incentives (monetary or otherwise) to an attending provider to
23 induce the provider to provide care to an insured in a manner
24 inconsistent with this Section.
25 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 

 

 

HB5192 - 51 - LRB095 17610 DRJ 45972 b

1     Section 15-35. The Voluntary Health Services Plans Act is
2 amended by changing Section 10 as follows:
 
3     (215 ILCS 165/10)  (from Ch. 32, par. 604)
4     Sec. 10. Application of Insurance Code provisions. Health
5 services plan corporations and all persons interested therein
6 or dealing therewith shall be subject to the provisions of
7 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
8 149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
9 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
10 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
11 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
12 and (15) of Section 367 of the Illinois Insurance Code.
13 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
14 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
15 8-28-07; revised 12-5-07.)
 
16     Section 99. Effective date. This Act takes effect upon
17 becoming law.

 

 

HB5192 - 52 - LRB095 17610 DRJ 45972 b

1 INDEX
2 Statutes amended in order of appearance
3     305 ILCS 5/5-5 from Ch. 23, par. 5-5
4     55 ILCS 5/5-1069 from Ch. 34, par. 5-1069
5     65 ILCS 5/10-4-2 from Ch. 24, par. 10-4-2
6     215 ILCS 5/356g from Ch. 73, par. 968g
7     215 ILCS 125/4-6.1 from Ch. 111 1/2, par. 1408.7
8     215 ILCS 5/356g.5-1 new
9     5 ILCS 375/6.11
10     55 ILCS 5/5-1069.3
11     65 ILCS 5/10-4-2.3
12     105 ILCS 5/10-22.3f
13     215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
14     215 ILCS 165/10 from Ch. 32, par. 604
15     215 ILCS 5/356g from Ch. 73, par. 968g
16     5 ILCS 375/6.11
17     55 ILCS 5/5-1069 from Ch. 34, par. 5-1069
18     55 ILCS 5/5-1069.3
19     65 ILCS 5/10-4-2 from Ch. 24, par. 10-4-2
20     65 ILCS 5/10-4-2.3
21     105 ILCS 5/10-22.3f
22     215 ILCS 125/4-6.1 from Ch. 111 1/2, par. 1408.7
23     215 ILCS 165/10 from Ch. 32, par. 604