Health & Healthcare Disparities Committee

Filed: 3/13/2008

 

 


 

 


 
09500HB5192ham001 LRB095 17610 DRJ 46973 a

1
AMENDMENT TO HOUSE BILL 5192

2     AMENDMENT NO. ______. Amend House Bill 5192 by replacing
3 everything after the enacting clause with the following:
 
4
"Article 1. Legislative Intent

 
5     Section 1-1. Legislative intent. The General Assembly
6 finds that the mortality associated with breast cancer for
7 minority women in Illinois is significantly higher compared to
8 non-minority women. This disparity has grown over the last 2
9 decades and is unacceptable. A recent New England Journal of
10 Medicine article found that even modest cost-sharing deters
11 women from getting a mammogram. The reduction was most
12 pronounced for those with lower income and less education. Many
13 other studies have found that women with lower family income
14 and those relying on public programs for healthcare access
15 mammography at a lower rate. It is, therefore, the intent of
16 this legislation to decrease health disparities as they relate

 

 

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1 to breast cancer and to improve access for all women to quality
2 breast cancer screening and treatment where necessary.
 
3
Article 5. Improving State Healthcare Programs
4
With Respect To
5
Mammography And Breast Cancer Treatment

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

 

 

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1 (12) prescribed drugs, dentures, and prosthetic devices; and
2 eyeglasses prescribed by a physician skilled in the diseases of
3 the eye, or by an optometrist, whichever the person may select;
4 (13) other diagnostic, screening, preventive, and
5 rehabilitative services; (14) transportation and such other
6 expenses as may be necessary; (15) medical treatment of sexual
7 assault survivors, as defined in Section 1a of the Sexual
8 Assault Survivors Emergency Treatment Act, for injuries
9 sustained as a result of the sexual assault, including
10 examinations and laboratory tests to discover evidence which
11 may be used in criminal proceedings arising from the sexual
12 assault; (16) the diagnosis and treatment of sickle cell
13 anemia; and (17) any other medical care, and any other type of
14 remedial care recognized under the laws of this State, but not
15 including abortions, or induced miscarriages or premature
16 births, unless, in the opinion of a physician, such procedures
17 are necessary for the preservation of the life of the woman
18 seeking such treatment, or except an induced premature birth
19 intended to produce a live viable child and such procedure is
20 necessary for the health of the mother or her unborn child. The
21 Illinois Department, by rule, shall prohibit any physician from
22 providing medical assistance to anyone eligible therefor under
23 this Code where such physician has been found guilty of
24 performing an abortion procedure in a wilful and wanton manner
25 upon a woman who was not pregnant at the time such abortion
26 procedure was performed. The term "any other type of remedial

 

 

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1 care" shall include nursing care and nursing home service for
2 persons who rely on treatment by spiritual means alone through
3 prayer for healing.
4     Notwithstanding any other provision of this Section, a
5 comprehensive tobacco use cessation program that includes
6 purchasing prescription drugs or prescription medical devices
7 approved by the Food and Drug administration shall be covered
8 under the medical assistance program under this Article for
9 persons who are otherwise eligible for assistance under this
10 Article.
11     Notwithstanding any other provision of this Code, the
12 Illinois Department may not require, as a condition of payment
13 for any laboratory test authorized under this Article, that a
14 physician's handwritten signature appear on the laboratory
15 test order form. The Illinois Department may, however, impose
16 other appropriate requirements regarding laboratory test order
17 documentation.
18     The Department of Healthcare and Family Services shall
19 provide the following services to persons eligible for
20 assistance under this Article who are participating in
21 education, training or employment programs operated by the
22 Department of Human Services as successor to the Department of
23 Public Aid:
24         (1) dental services, which shall include but not be
25     limited to prosthodontics; and
26         (2) eyeglasses prescribed by a physician skilled in the

 

 

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1     diseases of the eye, or by an optometrist, whichever the
2     person may select.
3     The Illinois Department, by rule, may distinguish and
4 classify the medical services to be provided only in accordance
5 with the classes of persons designated in Section 5-2.
6     The Department of Healthcare and Family Services must
7 provide coverage and reimbursement for amino acid-based
8 elemental formulas, regardless of delivery method, for the
9 diagnosis and treatment of (i) eosinophilic disorders and (ii)
10 short bowel syndrome when the prescribing physician has issued
11 a written order stating that the amino acid-based elemental
12 formula is medically necessary.
13     The Illinois Department shall authorize the provision of,
14 and shall authorize payment for, screening by low-dose
15 mammography for the presence of occult breast cancer for women
16 35 years of age or older who are eligible for medical
17 assistance under this Article, as follows:
18          (A) A a baseline mammogram for women 35 to 39 years of
19     age. and an
20         (B) An annual mammogram for women 40 years of age or
21     older.
22         (C) A mammogram at the age and intervals considered
23     medically necessary by the woman's health care provider for
24     women under 40 years of age and having a family history of
25     breast cancer, prior personal history of breast cancer,
26     positive genetic testing, or other risk factors.

 

 

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1         (D) 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     All screenings shall include a physical breast exam,
7 instruction on self-examination and information regarding the
8 frequency of self-examination and its value as a preventative
9 tool. For purposes of As used in this Section, "low-dose
10 mammography" means the x-ray examination of the breast using
11 equipment dedicated specifically for mammography, including
12 the x-ray tube, filter, compression device, and image receptor,
13 and cassettes, with an average radiation exposure delivery of
14 less than one rad per breast for mid-breast, with 2 views of an
15 average size for each breast. The term also includes digital
16 mammography.
17     On and after July 1, 2008, screening and diagnostic
18 mammography shall be reimbursed at the same rate as the
19 Medicare program's rates, including the increased
20 reimbursement for digital mammography.
21     The Department shall convene an expert panel including
22 representatives of hospitals, free-standing mammography
23 facilities, and doctors, including radiologists, to establish
24 quality standards. Based on these quality standards, the
25 Department shall provide for bonus payments to mammography
26 facilities meeting the standards for screening and diagnosis.

 

 

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1 The bonus payments shall be at least 15% higher than the
2 Medicare rates for mammography.
3     Subject to federal approval, the Department shall
4 establish a rate methodology for mammography at federally
5 qualified health centers and other encounter-rate clinics.
6 These clinics or centers may also collaborate with other
7 hospital-based mammography facilities.
8     The Department shall establish a methodology to remind
9 women who are age-appropriate for screening mammography, but
10 who have not received a mammogram within the previous 18
11 months, of the importance and benefit of screening mammography.
12     The Department shall establish a performance goal for
13 primary care providers with respect to their female patients
14 over age 40 receiving an annual mammogram. This performance
15 goal shall be used to provide additional reimbursement in the
16 form of a quality performance bonus to primary care providers
17 who meet that goal.
18     The Department shall devise a means of case-managing or
19 patient navigation for beneficiaries diagnosed with breast
20 cancer. This program shall initially operate as a pilot program
21 in areas of the State with the highest incidence of mortality
22 related to breast cancer. At least one pilot program site shall
23 be in the metropolitan Chicago area and at least one site shall
24 be outside the metropolitan Chicago area. An evaluation of the
25 pilot program shall be carried out measuring health outcomes
26 and cost of care for those served by the pilot program compared

 

 

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1 to similarly situated patients who are not served by the pilot
2 program.
3     Any medical or health care provider shall immediately
4 recommend, to any pregnant woman who is being provided prenatal
5 services and is suspected of drug abuse or is addicted as
6 defined in the Alcoholism and Other Drug Abuse and Dependency
7 Act, referral to a local substance abuse treatment provider
8 licensed by the Department of Human Services or to a licensed
9 hospital which provides substance abuse treatment services.
10 The Department of Healthcare and Family Services shall assure
11 coverage for the cost of treatment of the drug abuse or
12 addiction for pregnant recipients in accordance with the
13 Illinois Medicaid Program in conjunction with the Department of
14 Human Services.
15     All medical providers providing medical assistance to
16 pregnant women under this Code shall receive information from
17 the Department on the availability of services under the Drug
18 Free Families with a Future or any comparable program providing
19 case management services for addicted women, including
20 information on appropriate referrals for other social services
21 that may be needed by addicted women in addition to treatment
22 for addiction.
23     The Illinois Department, in cooperation with the
24 Departments of Human Services (as successor to the Department
25 of Alcoholism and Substance Abuse) and Public Health, through a
26 public awareness campaign, may provide information concerning

 

 

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1 treatment for alcoholism and drug abuse and addiction, prenatal
2 health care, and other pertinent programs directed at reducing
3 the number of drug-affected infants born to recipients of
4 medical assistance.
5     Neither the Department of Healthcare and Family Services
6 nor the Department of Human Services shall sanction the
7 recipient solely on the basis of her substance abuse.
8     The Illinois Department shall establish such regulations
9 governing the dispensing of health services under this Article
10 as it shall deem appropriate. The Department should seek the
11 advice of formal professional advisory committees appointed by
12 the Director of the Illinois Department for the purpose of
13 providing regular advice on policy and administrative matters,
14 information dissemination and educational activities for
15 medical and health care providers, and consistency in
16 procedures to the Illinois Department.
17     The Illinois Department may develop and contract with
18 Partnerships of medical providers to arrange medical services
19 for persons eligible under Section 5-2 of this Code.
20 Implementation of this Section may be by demonstration projects
21 in certain geographic areas. The Partnership shall be
22 represented by a sponsor organization. The Department, by rule,
23 shall develop qualifications for sponsors of Partnerships.
24 Nothing in this Section shall be construed to require that the
25 sponsor organization be a medical organization.
26     The sponsor must negotiate formal written contracts with

 

 

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1 medical providers for physician services, inpatient and
2 outpatient hospital care, home health services, treatment for
3 alcoholism and substance abuse, and other services determined
4 necessary by the Illinois Department by rule for delivery by
5 Partnerships. Physician services must include prenatal and
6 obstetrical care. The Illinois Department shall reimburse
7 medical services delivered by Partnership providers to clients
8 in target areas according to provisions of this Article and the
9 Illinois Health Finance Reform Act, except that:
10         (1) Physicians participating in a Partnership and
11     providing certain services, which shall be determined by
12     the Illinois Department, to persons in areas covered by the
13     Partnership may receive an additional surcharge for such
14     services.
15         (2) The Department may elect to consider and negotiate
16     financial incentives to encourage the development of
17     Partnerships and the efficient delivery of medical care.
18         (3) Persons receiving medical services through
19     Partnerships may receive medical and case management
20     services above the level usually offered through the
21     medical assistance program.
22     Medical providers shall be required to meet certain
23 qualifications to participate in Partnerships to ensure the
24 delivery of high quality medical services. These
25 qualifications shall be determined by rule of the Illinois
26 Department and may be higher than qualifications for

 

 

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1 participation in the medical assistance program. Partnership
2 sponsors may prescribe reasonable additional qualifications
3 for participation by medical providers, only with the prior
4 written approval of the Illinois Department.
5     Nothing in this Section shall limit the free choice of
6 practitioners, hospitals, and other providers of medical
7 services by clients. In order to ensure patient freedom of
8 choice, the Illinois Department shall immediately promulgate
9 all rules and take all other necessary actions so that provided
10 services may be accessed from therapeutically certified
11 optometrists to the full extent of the Illinois Optometric
12 Practice Act of 1987 without discriminating between service
13 providers.
14     The Department shall apply for a waiver from the United
15 States Health Care Financing Administration to allow for the
16 implementation of Partnerships under this Section.
17     The Illinois Department shall require health care
18 providers to maintain records that document the medical care
19 and services provided to recipients of Medical Assistance under
20 this Article. The Illinois Department shall require health care
21 providers to make available, when authorized by the patient, in
22 writing, the medical records in a timely fashion to other
23 health care providers who are treating or serving persons
24 eligible for Medical Assistance under this Article. All
25 dispensers of medical services shall be required to maintain
26 and retain business and professional records sufficient to

 

 

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1 fully and accurately document the nature, scope, details and
2 receipt of the health care provided to persons eligible for
3 medical assistance under this Code, in accordance with
4 regulations promulgated by the Illinois Department. The rules
5 and regulations shall require that proof of the receipt of
6 prescription drugs, dentures, prosthetic devices and
7 eyeglasses by eligible persons under this Section accompany
8 each claim for reimbursement submitted by the dispenser of such
9 medical services. No such claims for reimbursement shall be
10 approved for payment by the Illinois Department without such
11 proof of receipt, unless the Illinois Department shall have put
12 into effect and shall be operating a system of post-payment
13 audit and review which shall, on a sampling basis, be deemed
14 adequate by the Illinois Department to assure that such drugs,
15 dentures, prosthetic devices and eyeglasses for which payment
16 is being made are actually being received by eligible
17 recipients. Within 90 days after the effective date of this
18 amendatory Act of 1984, the Illinois Department shall establish
19 a current list of acquisition costs for all prosthetic devices
20 and any other items recognized as medical equipment and
21 supplies reimbursable under this Article and shall update such
22 list on a quarterly basis, except that the acquisition costs of
23 all prescription drugs shall be updated no less frequently than
24 every 30 days as required by Section 5-5.12.
25     The rules and regulations of the Illinois Department shall
26 require that a written statement including the required opinion

 

 

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1 of a physician shall accompany any claim for reimbursement for
2 abortions, or induced miscarriages or premature births. This
3 statement shall indicate what procedures were used in providing
4 such medical services.
5     The Illinois Department shall require all dispensers of
6 medical services, other than an individual practitioner or
7 group of practitioners, desiring to participate in the Medical
8 Assistance program established under this Article to disclose
9 all financial, beneficial, ownership, equity, surety or other
10 interests in any and all firms, corporations, partnerships,
11 associations, business enterprises, joint ventures, agencies,
12 institutions or other legal entities providing any form of
13 health care services in this State under this Article.
14     The Illinois Department may require that all dispensers of
15 medical services desiring to participate in the medical
16 assistance program established under this Article disclose,
17 under such terms and conditions as the Illinois Department may
18 by rule establish, all inquiries from clients and attorneys
19 regarding medical bills paid by the Illinois Department, which
20 inquiries could indicate potential existence of claims or liens
21 for the Illinois Department.
22     Enrollment of a vendor that provides non-emergency medical
23 transportation, defined by the Department by rule, shall be
24 conditional for 180 days. During that time, the Department of
25 Healthcare and Family Services may terminate the vendor's
26 eligibility to participate in the medical assistance program

 

 

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1 without cause. That termination of eligibility is not subject
2 to the Department's hearing process.
3     The Illinois Department shall establish policies,
4 procedures, standards and criteria by rule for the acquisition,
5 repair and replacement of orthotic and prosthetic devices and
6 durable medical equipment. Such rules shall provide, but not be
7 limited to, the following services: (1) immediate repair or
8 replacement of such devices by recipients without medical
9 authorization; and (2) rental, lease, purchase or
10 lease-purchase of durable medical equipment in a
11 cost-effective manner, taking into consideration the
12 recipient's medical prognosis, the extent of the recipient's
13 needs, and the requirements and costs for maintaining such
14 equipment. Such rules shall enable a recipient to temporarily
15 acquire and use alternative or substitute devices or equipment
16 pending repairs or replacements of any device or equipment
17 previously authorized for such recipient by the Department.
18     The Department shall execute, relative to the nursing home
19 prescreening project, written inter-agency agreements with the
20 Department of Human Services and the Department on Aging, to
21 effect the following: (i) intake procedures and common
22 eligibility criteria for those persons who are receiving
23 non-institutional services; and (ii) the establishment and
24 development of non-institutional services in areas of the State
25 where they are not currently available or are undeveloped.
26     The Illinois Department shall develop and operate, in

 

 

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1 cooperation with other State Departments and agencies and in
2 compliance with applicable federal laws and regulations,
3 appropriate and effective systems of health care evaluation and
4 programs for monitoring of utilization of health care services
5 and facilities, as it affects persons eligible for medical
6 assistance under this Code.
7     The Illinois Department shall report annually to the
8 General Assembly, no later than the second Friday in April of
9 1979 and each year thereafter, in regard to:
10         (a) actual statistics and trends in utilization of
11     medical services by public aid recipients;
12         (b) actual statistics and trends in the provision of
13     the various medical services by medical vendors;
14         (c) current rate structures and proposed changes in
15     those rate structures for the various medical vendors; and
16         (d) efforts at utilization review and control by the
17     Illinois Department.
18     The period covered by each report shall be the 3 years
19 ending on the June 30 prior to the report. The report shall
20 include suggested legislation for consideration by the General
21 Assembly. The filing of one copy of the report with the
22 Speaker, one copy with the Minority Leader and one copy with
23 the Clerk of the House of Representatives, one copy with the
24 President, one copy with the Minority Leader and one copy with
25 the Secretary of the Senate, one copy with the Legislative
26 Research Unit, and such additional copies with the State

 

 

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1 Government Report Distribution Center for the General Assembly
2 as is required under paragraph (t) of Section 7 of the State
3 Library Act shall be deemed sufficient to comply with this
4 Section.
5 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
 
6
Article 10. Breast Cancer Patients'
7
Access To Pain Relief

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

 

 

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1 apply to short-term travel, accident-only, limited, or
2 specified-disease policies, or to policies or contracts
3 designed for issuance to persons eligible for coverage under
4 Title XVIII of the Social Security Act, known as Medicare, or
5 any other similar coverage under State or federal governmental
6 plans.
 
7     Section 10-10. The State Employees Group Insurance Act of
8 1971 is amended by changing Section 6.11 as follows:
 
9     (5 ILCS 375/6.11)
10     Sec. 6.11. Required health benefits; Illinois Insurance
11 Code requirements. The program of health benefits shall provide
12 the post-mastectomy care benefits required to be covered by a
13 policy of accident and health insurance under Section 356t of
14 the Illinois Insurance Code. The program of health benefits
15 shall provide the coverage required under Sections 356g.5,
16 356g.5-1, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9,
17 and 356z.10 356z.9 of the Illinois Insurance Code. The program
18 of health benefits must comply with Section 155.37 of the
19 Illinois Insurance Code.
20 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
21 95-520, eff. 8-28-07; revised 12-4-07.)
 
22     Section 10-15. The Counties Code is amended by changing
23 Section 5-1069.3 as follows:
 

 

 

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1     (55 ILCS 5/5-1069.3)
2     Sec. 5-1069.3. Required health benefits. If a county,
3 including a home rule county, is a self-insurer for purposes of
4 providing health insurance coverage for its employees, the
5 coverage shall include coverage for the post-mastectomy care
6 benefits required to be covered by a policy of accident and
7 health insurance under Section 356t and the coverage required
8 under Sections 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, and
9 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
10 requirement that health benefits be covered as provided in this
11 Section is an exclusive power and function of the State and is
12 a denial and limitation under Article VII, Section 6,
13 subsection (h) of the Illinois Constitution. A home rule county
14 to which this Section applies must comply with every provision
15 of this Section.
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 10-20. The Illinois Municipal Code is amended by
19 changing Section 10-4-2.3 as follows:
 
20     (65 ILCS 5/10-4-2.3)
21     Sec. 10-4-2.3. Required health benefits. If a
22 municipality, including a home rule municipality, is a
23 self-insurer for purposes of providing health insurance

 

 

09500HB5192ham001 - 19 - LRB095 17610 DRJ 46973 a

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

 

 

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

 

 

09500HB5192ham001 - 21 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 22 - LRB095 17610 DRJ 46973 a

1         the Health Maintenance Organization sought to be
2         acquired as of the end of the preceding year and as of
3         a date 90 days prior to the acquisition, as well as pro
4         forma financial statements reflecting projected
5         combined operation for a period of 2 years;
6             (C) a pro forma business plan detailing an
7         acquiring party's plans with respect to the operation
8         of the Health Maintenance Organization sought to be
9         acquired for a period of not less than 3 years; and
10             (D) such other information as the Director shall
11         require.
12     (d) The provisions of Article VIII 1/2 of the Illinois
13 Insurance Code and this Section 5-3 shall apply to the sale by
14 any health maintenance organization of greater than 10% of its
15 enrollee population (including without limitation the health
16 maintenance organization's right, title, and interest in and to
17 its health care certificates).
18     (e) In considering any management contract or service
19 agreement subject to Section 141.1 of the Illinois Insurance
20 Code, the Director (i) shall, in addition to the criteria
21 specified in Section 141.2 of the Illinois Insurance Code, take
22 into account the effect of the management contract or service
23 agreement on the continuation of benefits to enrollees and the
24 financial condition of the health maintenance organization to
25 be managed or serviced, and (ii) need not take into account the
26 effect of the management contract or service agreement on

 

 

09500HB5192ham001 - 23 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 24 - LRB095 17610 DRJ 46973 a

1     or unprofitable experience may be calculated taking into
2     account the refund period and the immediately preceding 2
3     plan years.
4     The Health Maintenance Organization shall include a
5 statement in the evidence of coverage issued to each enrollee
6 describing the possibility of a refund or additional premium,
7 and upon request of any group or enrollment unit, provide to
8 the group or enrollment unit a description of the method used
9 to calculate (1) the Health Maintenance Organization's
10 profitable experience with respect to the group or enrollment
11 unit and the resulting refund to the group or enrollment unit
12 or (2) the Health Maintenance Organization's unprofitable
13 experience with respect to the group or enrollment unit and the
14 resulting additional premium to be paid by the group or
15 enrollment unit.
16     In no event shall the Illinois Health Maintenance
17 Organization Guaranty Association be liable to pay any
18 contractual obligation of an insolvent organization to pay any
19 refund authorized under this Section.
20 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;
21 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
22     Section 10-35. The Voluntary Health Services Plans Act is
23 amended by changing Section 10 as follows:
 
24     (215 ILCS 165/10)  (from Ch. 32, par. 604)

 

 

09500HB5192ham001 - 25 - LRB095 17610 DRJ 46973 a

1     Sec. 10. Application of Insurance Code provisions. Health
2 services plan corporations and all persons interested therein
3 or dealing therewith shall be subject to the provisions of
4 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
5 149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u,
6 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
7 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
8 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
9 and (15) of Section 367 of the Illinois Insurance Code.
10 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
11 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
12 8-28-07; revised 12-5-07.)
 
13
Article 15. Reducing Financial Barriers To Mammography

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

 

 

09500HB5192ham001 - 26 - LRB095 17610 DRJ 46973 a

1 coverage shall be as follows:
2         (1) A baseline mammogram for women 35 to 39 years of
3     age.
4         (2) An annual mammogram for women 40 years of age or
5     older.
6         (3) A mammogram at the age and intervals considered
7     medically necessary by the woman's health care provider for
8     women under 40 years of age and having a family history of
9     breast cancer, prior personal history of breast cancer,
10     positive genetic testing, or other risk factors.
11         (4) A comprehensive ultrasound screening of an entire
12     breast or breasts if a mammogram demonstrates
13     heterogeneous or dense breast tissue, when medically
14     necessary as determined by a physician licensed to practice
15     medicine in all of its branches.
16     These benefits shall be at least as favorable as for other
17 radiological examinations and subject to the same dollar
18 limits, deductibles, and co-insurance factors. For purposes of
19 this Section, "low-dose mammography" means the x-ray
20 examination of the breast using equipment dedicated
21 specifically for mammography, including the x-ray tube,
22 filter, compression device, and image receptor, with radiation
23 exposure delivery of less than 1 rad per breast for 2 views of
24 an average size breast. The term also includes digital
25 mammography.
26     (a-5) Coverage as described by subsection (a) shall be

 

 

09500HB5192ham001 - 27 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 28 - LRB095 17610 DRJ 46973 a

1 Care shall be determined in consultation with the attending
2 physician and the patient. The offered coverage for prosthetic
3 devices and reconstructive surgery shall be subject to the
4 deductible and coinsurance conditions applied to the
5 mastectomy, and all other terms and conditions applicable to
6 other benefits. When a mastectomy is performed and there is no
7 evidence of malignancy then the offered coverage may be limited
8 to the provision of prosthetic devices and reconstructive
9 surgery to within 2 years after the date of the mastectomy. As
10 used in this Section, "mastectomy" means the removal of all or
11 part of the breast for medically necessary reasons, as
12 determined by a licensed physician.
13     Written notice of the availability of coverage under this
14 Section shall be delivered to the insured upon enrollment and
15 annually thereafter. An insurer may not deny to an insured
16 eligibility, or continued eligibility, to enroll or to renew
17 coverage under the terms of the plan solely for the purpose of
18 avoiding the requirements of this Section. An insurer may not
19 penalize or reduce or limit the reimbursement of an attending
20 provider or provide incentives (monetary or otherwise) to an
21 attending provider to induce the provider to provide care to an
22 insured in a manner inconsistent with this Section.
23 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
24     Section 15-10. The State Employees Group Insurance Act of
25 1971 is amended by changing Section 6.11 as follows:
 

 

 

09500HB5192ham001 - 29 - LRB095 17610 DRJ 46973 a

1     (5 ILCS 375/6.11)
2     Sec. 6.11. Required health benefits; Illinois Insurance
3 Code requirements. The program of health benefits shall provide
4 the post-mastectomy care benefits required to be covered by a
5 policy of accident and health insurance under Section 356t of
6 the Illinois Insurance Code. The program of health benefits
7 shall provide the coverage required under Sections 356g,
8 356g.5, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9,
9 and 356z.10 356z.9 of the Illinois Insurance Code. The program
10 of health benefits must comply with Section 155.37 of the
11 Illinois Insurance Code.
12 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
13 95-520, eff. 8-28-07; revised 12-4-07.)
 
14     Section 15-15. The Counties Code is amended by changing
15 Sections 5-1069 and 5-1069.3 as follows:
 
16     (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
17     Sec. 5-1069. Group life, health, accident, hospital, and
18 medical insurance.
19     (a) The county board of any county may arrange to provide,
20 for the benefit of employees of the county, group life, health,
21 accident, hospital, and medical insurance, or any one or any
22 combination of those types of insurance, or the county board
23 may self-insure, for the benefit of its employees, all or a

 

 

09500HB5192ham001 - 30 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 31 - LRB095 17610 DRJ 46973 a

1 it makes arrangements to provide group insurance through an
2 insurance carrier, if the kinds of group insurance are obtained
3 from an insurance company authorized to do business in the
4 State of Illinois. The county board may enact an ordinance
5 prescribing the method of operation of the insurance program.
6     (d) If a county, including a home rule county, is a
7 self-insurer for purposes of providing health insurance
8 coverage for its employees, the insurance coverage shall
9 include screening by low-dose mammography for all women 35
10 years of age or older for the presence of occult breast cancer
11 unless the county elects to provide mammograms itself under
12 Section 5-1069.1. The coverage shall be as follows:
13         (1) A baseline mammogram for women 35 to 39 years of
14     age.
15         (2) An annual mammogram for women 40 years of age or
16     older.
17         (3) A mammogram at the age and intervals considered
18     medically necessary by the woman's health care provider for
19     women under 40 years of age and having a family history of
20     breast cancer, prior personal history of breast cancer,
21     positive genetic testing, or other risk factors.
22         (4) A comprehensive ultrasound screening of an entire
23     breast or breasts if a mammogram demonstrates
24     heterogeneous or dense breast tissue, when medically
25     necessary as determined by a physician licensed to practice
26     medicine in all of its branches.

 

 

09500HB5192ham001 - 32 - LRB095 17610 DRJ 46973 a

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 receptor
8 receptors, with an average radiation exposure delivery of less
9 than one rad per breast for mid-breast, with 2 views of an
10 average size for each breast. The term also includes digital
11 mammography.
12     (d-5) Coverage as described by subsection (d) shall be
13 provided at no cost to the insured and shall not be applied to
14 an annual or lifetime maximum benefit.
15     (d-10) When health care services are available through
16 contracted providers and a person does not comply with plan
17 provisions specific to the use of contracted providers, the
18 requirements of subsection (d-5) are not applicable. When a
19 person does not comply with plan provisions specific to the use
20 of contracted providers, plan provisions specific to the use of
21 non-contracted providers must be applied without distinction
22 for coverage required by this Section and shall be at least as
23 favorable as for other radiological examinations covered by the
24 policy or contract.
25     (d-15) If a county, including a home rule county, is a
26 self-insurer for purposes of providing health insurance

 

 

09500HB5192ham001 - 33 - LRB095 17610 DRJ 46973 a

1 coverage for its employees, the insurance coverage shall
2 include mastectomy coverage, which includes coverage for
3 prosthetic devices or reconstructive surgery incident to the
4 mastectomy. Coverage for breast reconstruction in connection
5 with a mastectomy shall include:
6         (1) reconstruction of the breast upon which the
7     mastectomy has been performed;
8         (2) surgery and reconstruction of the other breast to
9     produce a symmetrical appearance; and
10         (3) prostheses and treatment for physical
11     complications at all stages of mastectomy, including
12     lymphedemas.
13 Care shall be determined in consultation with the attending
14 physician and the patient. The offered coverage for prosthetic
15 devices and reconstructive surgery shall be subject to the
16 deductible and coinsurance conditions applied to the
17 mastectomy, and all other terms and conditions applicable to
18 other benefits. When a mastectomy is performed and there is no
19 evidence of malignancy then the offered coverage may be limited
20 to the provision of prosthetic devices and reconstructive
21 surgery to within 2 years after the date of the mastectomy. As
22 used in this Section, "mastectomy" means the removal of all or
23 part of the breast for medically necessary reasons, as
24 determined by a licensed physician.
25     A county, including a home rule county, that is a
26 self-insurer for purposes of providing health insurance

 

 

09500HB5192ham001 - 34 - LRB095 17610 DRJ 46973 a

1 coverage for its employees, may not penalize or reduce or limit
2 the reimbursement of an attending provider or provide
3 incentives (monetary or otherwise) to an attending provider to
4 induce the provider to provide care to an insured in a manner
5 inconsistent with this Section.
6     (d-20) The requirement that mammograms be included in
7 health insurance coverage as provided in subsections this
8 subsection (d) through (d-15) is an exclusive power and
9 function of the State and is a denial and limitation under
10 Article VII, Section 6, subsection (h) of the Illinois
11 Constitution of home rule county powers. A home rule county to
12 which subsections (d) through (d-15) apply this subsection
13 applies must comply with every provision of those subsections
14 this subsection.
15     (e) The term "employees" as used in this Section includes
16 elected or appointed officials but does not include temporary
17 employees.
18     (f) The county board may, by ordinance, arrange to provide
19 group life, health, accident, hospital, and medical insurance,
20 or any one or a combination of those types of insurance, under
21 this Section to retired former employees and retired former
22 elected or appointed officials of the county.
23 (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
 
24     (55 ILCS 5/5-1069.3)
25     Sec. 5-1069.3. Required health benefits. If a county,

 

 

09500HB5192ham001 - 35 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 36 - LRB095 17610 DRJ 46973 a

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

 

 

09500HB5192ham001 - 37 - LRB095 17610 DRJ 46973 a

1 under the Intergovernmental Cooperation Act. The corporate
2 authorities may enact an ordinance prescribing the method of
3 operation of the insurance program.
4     (d) If a municipality, including a home rule municipality,
5 is a 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 municipality elects to provide mammograms itself
10 under Section 10-4-2.1. 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         (3) A mammogram at the age and intervals considered
16     medically necessary by the woman's health care provider for
17     women under 40 years of age and having a family history of
18     breast cancer, prior personal history of breast cancer,
19     positive genetic testing, or other risk factors.
20         (4) A comprehensive ultrasound screening of an entire
21     breast or breasts if a mammogram demonstrates
22     heterogeneous or dense breast tissue, when medically
23     necessary as determined by a physician licensed to practice
24     medicine in all of its branches.
25     Those benefits shall be at least as favorable as for other
26 radiological examinations and subject to the same dollar

 

 

09500HB5192ham001 - 38 - LRB095 17610 DRJ 46973 a

1 limits, deductibles, and co-insurance factors. For purposes of
2 this subsection, "low-dose mammography" means the x-ray
3 examination of the breast using equipment dedicated
4 specifically for mammography, including the x-ray tube,
5 filter, compression device, screens, and image receptor
6 receptors, with an average radiation exposure delivery of less
7 than one rad per breast for mid-breast, with 2 views of an
8 average size for each breast. The term also includes digital
9 mammography.
10     (d-5) Coverage as described by subsection (d) shall be
11 provided at no cost to the insured and shall not be applied to
12 an annual or lifetime maximum benefit.
13     (d-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 (d-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     (d-15) If a municipality, including a home rule
24 municipality, is a self-insurer for purposes of providing
25 health insurance coverage for its employees, the insurance
26 coverage shall include mastectomy coverage, which includes

 

 

09500HB5192ham001 - 39 - LRB095 17610 DRJ 46973 a

1 coverage for prosthetic devices or reconstructive surgery
2 incident to the mastectomy. Coverage for breast reconstruction
3 in connection with a mastectomy shall include:
4         (1) reconstruction of the breast upon which the
5     mastectomy has been performed;
6         (2) surgery and reconstruction of the other breast to
7     produce a symmetrical appearance; and
8         (3) prostheses and treatment for physical
9     complications at all stages of mastectomy, including
10     lymphedemas.
11 Care shall be determined in consultation with the attending
12 physician and the patient. The offered coverage for prosthetic
13 devices and reconstructive surgery shall be subject to the
14 deductible and coinsurance conditions applied to the
15 mastectomy, and all other terms and conditions applicable to
16 other benefits. When a mastectomy is performed and there is no
17 evidence of malignancy then the offered coverage may be 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     A municipality, including a home rule municipality, that is
24 a self-insurer for purposes of providing health insurance
25 coverage for its employees, may not penalize or reduce or limit
26 the reimbursement of an attending provider or provide

 

 

09500HB5192ham001 - 40 - LRB095 17610 DRJ 46973 a

1 incentives (monetary or otherwise) to an attending provider to
2 induce the provider to provide care to an insured in a manner
3 inconsistent with this Section.
4     (d-20) The requirement that mammograms be included in
5 health insurance coverage as provided in subsections this
6 subsection (d) through (d-15) is an exclusive power and
7 function of the State and is a denial and limitation under
8 Article VII, Section 6, subsection (h) of the Illinois
9 Constitution of home rule municipality powers. A home rule
10 municipality to which subsections (d) through (d-15) apply this
11 subsection applies must comply with every provision of through
12 subsections this subsection.
13 (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
 
14     (65 ILCS 5/10-4-2.3)
15     Sec. 10-4-2.3. Required health benefits. If a
16 municipality, including a home rule municipality, is a
17 self-insurer for purposes of providing health insurance
18 coverage for its employees, the coverage shall include coverage
19 for the post-mastectomy care benefits required to be covered by
20 a policy of accident and health insurance under Section 356t
21 and the coverage required under Sections 356g, 356g.5, 356u,
22 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the
23 Illinois Insurance Code. The requirement that health benefits
24 be covered as provided in this is an exclusive power and
25 function of the State and is a denial and limitation under

 

 

09500HB5192ham001 - 41 - LRB095 17610 DRJ 46973 a

1 Article VII, Section 6, subsection (h) of the Illinois
2 Constitution. A home rule municipality to which this Section
3 applies must comply with every provision of this Section.
4 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
5 95-520, eff. 8-28-07; revised 12-4-07.)
 
6     Section 15-25. The School Code is amended by changing
7 Section 10-22.3f as follows:
 
8     (105 ILCS 5/10-22.3f)
9     Sec. 10-22.3f. Required health benefits. Insurance
10 protection and benefits for employees shall provide the
11 post-mastectomy care benefits required to be covered by a
12 policy of accident and health insurance under Section 356t and
13 the coverage required under Sections 356g, 356g.5, 356u, 356w,
14 356x, 356z.6, and 356z.9 of the Illinois Insurance Code.
15 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
16 revised 12-4-07.)
 
17     Section 15-30. The Health Maintenance Organization Act is
18 amended by changing Section 4-6.1 as follows:
 
19     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
20     Sec. 4-6.1. Mammograms; mastectomies.
21     (a) Every contract or evidence of coverage issued by a
22 Health Maintenance Organization for persons who are residents

 

 

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1 of this State shall contain coverage for screening by low-dose
2 mammography for all women 35 years of age or older for the
3 presence of occult breast cancer. The coverage shall be as
4 follows:
5         (1) A baseline mammogram for women 35 to 39 years of
6     age.
7         (2) An annual mammogram for women 40 years of age or
8     older.
9         (3) A mammogram at the age and intervals considered
10     medically necessary by the woman's health care provider for
11     women under 40 years of age and having a family history of
12     breast cancer, prior personal history of breast cancer,
13     positive genetic testing, or other risk factors.
14         (4) A comprehensive ultrasound screening of an entire
15     breast or breasts if a mammogram demonstrates
16     heterogeneous or dense breast tissue, when medically
17     necessary as determined by a physician licensed to practice
18     medicine in all of its branches.
19     These benefits shall be at least as favorable as for other
20 radiological examinations and subject to the same dollar
21 limits, deductibles, and co-insurance factors. For purposes of
22 this Section, "low-dose mammography" means the x-ray
23 examination of the breast using equipment dedicated
24 specifically for mammography, including the x-ray tube,
25 filter, compression device, and image receptor, with radiation
26 exposure delivery of less than 1 rad per breast for 2 views of

 

 

09500HB5192ham001 - 43 - LRB095 17610 DRJ 46973 a

1 an average size breast. The term also includes digital
2 mammography.
3     (a-5) Coverage as described in subsection (a) shall be
4 provided at no cost to the enrollee and shall not be applied to
5 an annual or lifetime maximum benefit.
6     (b) No contract or evidence of coverage issued by a health
7 maintenance organization that provides for the surgical
8 procedure known as a mastectomy shall be issued, amended,
9 delivered, or renewed in this State on or after the effective
10 date of this amendatory Act of the 92nd General Assembly unless
11 that coverage also provides for prosthetic devices or
12 reconstructive surgery incident to the mastectomy, providing
13 that the mastectomy is performed after the effective date of
14 this amendatory Act. Coverage for breast reconstruction in
15 connection with a mastectomy shall include:
16         (1) reconstruction of the breast upon which the
17     mastectomy has been performed;
18         (2) surgery and reconstruction of the other breast to
19     produce a symmetrical appearance; and
20         (3) prostheses and treatment for physical
21     complications at all stages of mastectomy, including
22     lymphedemas.
23 Care shall be determined in consultation with the attending
24 physician and the patient. The offered coverage for prosthetic
25 devices and reconstructive surgery shall be subject to the
26 deductible and coinsurance conditions applied to the

 

 

09500HB5192ham001 - 44 - LRB095 17610 DRJ 46973 a

1 mastectomy and all other terms and conditions applicable to
2 other benefits. When a mastectomy is performed and there is no
3 evidence of malignancy, then the offered coverage may be
4 limited to the provision of prosthetic devices and
5 reconstructive surgery to within 2 years after the date of the
6 mastectomy. As used in this Section, "mastectomy" means the
7 removal of all or part of the breast for medically necessary
8 reasons, as determined by a licensed physician.
9     Written notice of the availability of coverage under this
10 Section shall be delivered to the enrollee upon enrollment and
11 annually thereafter. A health maintenance organization may not
12 deny to an enrollee eligibility, or continued eligibility, to
13 enroll or to renew coverage under the terms of the plan solely
14 for the purpose of avoiding the requirements of this Section. A
15 health maintenance organization may not penalize or reduce or
16 limit the reimbursement of an attending provider or provide
17 incentives (monetary or otherwise) to an attending provider to
18 induce the provider to provide care to an insured in a manner
19 inconsistent with this Section.
20 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
21     Section 15-35. The Voluntary Health Services Plans Act is
22 amended by changing Section 10 as follows:
 
23     (215 ILCS 165/10)  (from Ch. 32, par. 604)
24     Sec. 10. Application of Insurance Code provisions. Health

 

 

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