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Public Act 095-0431
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| SB1365 Enrolled |
LRB095 04641 KBJ 24699 b |
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AN ACT concerning insurance.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
changing Section 356g as follows:
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(215 ILCS 5/356g) (from Ch. 73, par. 968g)
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Sec. 356g. Mammograms; mastectomies.
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(a) Every insurer shall provide in each group or individual
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policy, contract, or certificate of insurance issued or renewed |
for persons
who are residents of this State, coverage for |
screening by low-dose
mammography for all women 35 years of age |
or older for the presence of
occult breast cancer within the |
provisions of the policy, contract, or
certificate. The |
coverage shall be as follows:
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(1) A baseline mammogram for women 35 to 39 years of |
age.
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(2) An annual mammogram for women 40 years of age or |
older.
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(3) A mammogram at the age and intervals considered |
medically necessary by the woman's health care provider for |
women under 40 years of age and having a family history of |
breast cancer, prior personal history of breast cancer, |
positive genetic testing, or other risk factors.
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(4) A comprehensive ultrasound screening of an entire |
breast or breasts if a mammogram demonstrates |
heterogeneous or dense breast tissue, when medically |
necessary as determined by a physician licensed to practice |
medicine in all of its branches.
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These benefits shall be at least as favorable as for other |
radiological
examinations and subject to the same dollar |
limits, deductibles, and
co-insurance factors. For purposes of |
this Section, "low-dose mammography"
means the x-ray |
examination of the breast using equipment dedicated
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specifically for mammography, including the x-ray tube, |
filter, compression
device, and image receptor, with radiation |
exposure delivery of less than
1 rad per breast for 2 views of |
an average size breast.
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(b) No policy of accident or health insurance that provides |
for
the surgical procedure known as a mastectomy shall be |
issued, amended,
delivered, or renewed in this State unless
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that coverage also provides for prosthetic devices
or |
reconstructive surgery
incident to the mastectomy.
Coverage |
for breast reconstruction in connection with a mastectomy shall
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include:
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(1) reconstruction of the breast upon which the |
mastectomy has been
performed;
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(2) surgery and reconstruction of the other breast to |
produce a
symmetrical appearance; and
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(3) prostheses and treatment for physical |
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complications at all stages of
mastectomy, including |
lymphedemas.
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Care shall be determined in consultation with the attending |
physician and the
patient.
The offered coverage for prosthetic |
devices and
reconstructive surgery shall be subject to the |
deductible and coinsurance
conditions applied to the |
mastectomy, and all other terms and conditions
applicable to |
other benefits. When a mastectomy is performed and there is
no |
evidence of malignancy then the offered coverage may be limited |
to the
provision of prosthetic devices and reconstructive |
surgery to within 2
years after the date of the mastectomy. As |
used in this Section,
"mastectomy" means the removal of all or |
part of the breast for medically
necessary reasons, as |
determined by a licensed physician.
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Written notice of the availability of coverage under this |
Section shall be
delivered to the insured upon enrollment and |
annually thereafter. An insurer
may not deny to an insured |
eligibility, or continued eligibility, to enroll or
to renew |
coverage under the terms of the plan solely for the purpose of
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avoiding the requirements of this Section. An insurer may not |
penalize or
reduce or
limit the reimbursement of an attending |
provider or provide incentives
(monetary or otherwise) to an |
attending provider to induce the provider to
provide care to an |
insured in a manner inconsistent with this Section.
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(Source: P.A. 94-121, eff. 7-6-05.)
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Section 10. The Health Maintenance Organization Act is |
amended by changing Section 4-6.1 as follows:
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(215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
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Sec. 4-6.1. Mammograms; mastectomies.
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(a) Every contract or evidence of coverage
issued by a |
Health Maintenance Organization for persons who are residents |
of
this State shall contain coverage for screening by low-dose |
mammography
for all women 35 years of age or older for the |
presence of occult breast
cancer. The coverage shall be as |
follows:
|
(1) A baseline mammogram for women 35 to 39 years of |
age.
|
(2) An annual mammogram for women 40 years of age or |
older.
|
(3) A mammogram at the age and intervals considered |
medically necessary by the woman's health care provider for |
women under 40 years of age and having a family history of |
breast cancer, prior personal history of breast cancer, |
positive genetic testing, or other risk factors. |
(4) A comprehensive ultrasound screening of an entire |
breast or breasts if a mammogram demonstrates |
heterogeneous or dense breast tissue, when medically |
necessary as determined by a physician licensed to practice |
medicine in all of its branches.
|
These benefits shall be at least as favorable as for other |
|
radiological
examinations and subject to the same dollar |
limits, deductibles, and
co-insurance factors. For purposes of |
this Section, "low-dose mammography"
means the x-ray |
examination of the breast using equipment dedicated
|
specifically for mammography, including the x-ray tube, |
filter, compression
device, and image receptor, with radiation |
exposure delivery of less than 1
rad per breast for 2 views of |
an average size breast.
|
(b) No contract or evidence of coverage issued by a health |
maintenance
organization that provides for the
surgical |
procedure known as a mastectomy shall be issued, amended, |
delivered,
or renewed in this State on or after the effective |
date of this amendatory Act
of the 92nd General Assembly unless |
that coverage also provides for prosthetic
devices or |
reconstructive surgery incident to the mastectomy, providing |
that
the mastectomy is performed after the effective date of |
this amendatory Act.
Coverage for breast reconstruction in |
connection
with a mastectomy shall
include:
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(1) reconstruction of the breast upon which the |
mastectomy has been
performed;
|
(2) surgery and reconstruction of the other breast to |
produce a
symmetrical appearance; and
|
(3) prostheses and treatment for physical |
complications at all stages of
mastectomy, including |
lymphedemas.
|
Care shall be determined in consultation with the attending |
|
physician and the
patient.
The offered coverage for prosthetic |
devices and
reconstructive surgery shall be subject to the |
deductible and coinsurance
conditions applied to the |
mastectomy and all other terms and conditions
applicable to |
other benefits. When a mastectomy is performed and there is
no |
evidence of malignancy, then the offered coverage may be |
limited to the
provision of prosthetic devices and |
reconstructive surgery to within 2
years after the date of the |
mastectomy. As used in this Section,
"mastectomy" means the |
removal of all or part of the breast for medically
necessary |
reasons, as determined by a licensed physician.
|
Written notice of the availability of coverage under this |
Section shall be
delivered to the enrollee upon enrollment and |
annually thereafter. A
health maintenance organization may not |
deny to an enrollee eligibility, or
continued eligibility, to |
enroll or
to renew coverage under the terms of the plan solely |
for the purpose of
avoiding the requirements of this Section. A |
health maintenance organization
may not penalize or
reduce or
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limit the reimbursement of an attending provider or provide |
incentives
(monetary or otherwise) to an attending provider to |
induce the provider to
provide care to an insured in a manner |
inconsistent with this Section.
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(Source: P.A. 94-121, eff. 7-6-05.)
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Section 99. Effective date. This Act takes effect upon |
becoming law.
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