HB5192 Engrossed 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:
12          (A) A a baseline mammogram for women 35 to 39 years of
13     age. and an
14         (B) An annual mammogram for women 40 years of age or
15     older.
16         (C) 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         (D) 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
25     medicine in all of its branches.
26     All screenings shall include a physical breast exam,

 

 

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

 

 

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1 hospital-based mammography facilities.
2     The Department shall establish a methodology to remind
3 women who are age-appropriate for screening mammography, but
4 who have not received a mammogram within the previous 18
5 months, of the importance and benefit of screening mammography.
6     The Department shall establish a performance goal for
7 primary care providers with respect to their female patients
8 over age 40 receiving an annual mammogram. This performance
9 goal shall be used to provide additional reimbursement in the
10 form of a quality performance bonus to primary care providers
11 who meet that goal.
12     The Department shall devise a means of case-managing or
13 patient navigation for beneficiaries diagnosed with breast
14 cancer. This program shall initially operate as a pilot program
15 in areas of the State with the highest incidence of mortality
16 related to breast cancer. At least one pilot program site shall
17 be in the metropolitan Chicago area and at least one site shall
18 be outside the metropolitan Chicago area. An evaluation of the
19 pilot program shall be carried out measuring health outcomes
20 and cost of care for those served by the pilot program compared
21 to similarly situated patients who are not served by the pilot
22 program.
23     Any medical or health care provider shall immediately
24 recommend, to any pregnant woman who is being provided prenatal
25 services and is suspected of drug abuse or is addicted as
26 defined in the Alcoholism and Other Drug Abuse and Dependency

 

 

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1 Act, referral to a local substance abuse treatment provider
2 licensed by the Department of Human Services or to a licensed
3 hospital which provides substance abuse treatment services.
4 The Department of Healthcare and Family Services shall assure
5 coverage for the cost of treatment of the drug abuse or
6 addiction for pregnant recipients in accordance with the
7 Illinois Medicaid Program in conjunction with the Department of
8 Human Services.
9     All medical providers providing medical assistance to
10 pregnant women under this Code shall receive information from
11 the Department on the availability of services under the Drug
12 Free Families with a Future or any comparable program providing
13 case management services for addicted women, including
14 information on appropriate referrals for other social services
15 that may be needed by addicted women in addition to treatment
16 for addiction.
17     The Illinois Department, in cooperation with the
18 Departments of Human Services (as successor to the Department
19 of Alcoholism and Substance Abuse) and Public Health, through a
20 public awareness campaign, may provide information concerning
21 treatment for alcoholism and drug abuse and addiction, prenatal
22 health care, and other pertinent programs directed at reducing
23 the number of drug-affected infants born to recipients of
24 medical assistance.
25     Neither the Department of Healthcare and Family Services
26 nor the Department of Human Services shall sanction the

 

 

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1 recipient solely on the basis of her substance abuse.
2     The Illinois Department shall establish such regulations
3 governing the dispensing of health services under this Article
4 as it shall deem appropriate. The Department should seek the
5 advice of formal professional advisory committees appointed by
6 the Director of the Illinois Department for the purpose of
7 providing regular advice on policy and administrative matters,
8 information dissemination and educational activities for
9 medical and health care providers, and consistency in
10 procedures to the Illinois Department.
11     The Illinois Department may develop and contract with
12 Partnerships of medical providers to arrange medical services
13 for persons eligible under Section 5-2 of this Code.
14 Implementation of this Section may be by demonstration projects
15 in certain geographic areas. The Partnership shall be
16 represented by a sponsor organization. The Department, by rule,
17 shall develop qualifications for sponsors of Partnerships.
18 Nothing in this Section shall be construed to require that the
19 sponsor organization be a medical organization.
20     The sponsor must negotiate formal written contracts with
21 medical providers for physician services, inpatient and
22 outpatient hospital care, home health services, treatment for
23 alcoholism and substance abuse, and other services determined
24 necessary by the Illinois Department by rule for delivery by
25 Partnerships. Physician services must include prenatal and
26 obstetrical care. The Illinois Department shall reimburse

 

 

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1 medical services delivered by Partnership providers to clients
2 in target areas according to provisions of this Article and the
3 Illinois Health Finance Reform Act, except that:
4         (1) Physicians participating in a Partnership and
5     providing certain services, which shall be determined by
6     the Illinois Department, to persons in areas covered by the
7     Partnership may receive an additional surcharge for such
8     services.
9         (2) The Department may elect to consider and negotiate
10     financial incentives to encourage the development of
11     Partnerships and the efficient delivery of medical care.
12         (3) Persons receiving medical services through
13     Partnerships may receive medical and case management
14     services above the level usually offered through the
15     medical assistance program.
16     Medical providers shall be required to meet certain
17 qualifications to participate in Partnerships to ensure the
18 delivery of high quality medical services. These
19 qualifications shall be determined by rule of the Illinois
20 Department and may be higher than qualifications for
21 participation in the medical assistance program. Partnership
22 sponsors may prescribe reasonable additional qualifications
23 for participation by medical providers, only with the prior
24 written approval of the Illinois Department.
25     Nothing in this Section shall limit the free choice of
26 practitioners, hospitals, and other providers of medical

 

 

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1 services by clients. In order to ensure patient freedom of
2 choice, the Illinois Department shall immediately promulgate
3 all rules and take all other necessary actions so that provided
4 services may be accessed from therapeutically certified
5 optometrists to the full extent of the Illinois Optometric
6 Practice Act of 1987 without discriminating between service
7 providers.
8     The Department shall apply for a waiver from the United
9 States Health Care Financing Administration to allow for the
10 implementation of Partnerships under this Section.
11     The Illinois Department shall require health care
12 providers to maintain records that document the medical care
13 and services provided to recipients of Medical Assistance under
14 this Article. The Illinois Department shall require health care
15 providers to make available, when authorized by the patient, in
16 writing, the medical records in a timely fashion to other
17 health care providers who are treating or serving persons
18 eligible for Medical Assistance under this Article. All
19 dispensers of medical services shall be required to maintain
20 and retain business and professional records sufficient to
21 fully and accurately document the nature, scope, details and
22 receipt of the health care provided to persons eligible for
23 medical assistance under this Code, in accordance with
24 regulations promulgated by the Illinois Department. The rules
25 and regulations shall require that proof of the receipt of
26 prescription drugs, dentures, prosthetic devices and

 

 

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

 

 

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1 group of practitioners, desiring to participate in the Medical
2 Assistance program established under this Article to disclose
3 all financial, beneficial, ownership, equity, surety or other
4 interests in any and all firms, corporations, partnerships,
5 associations, business enterprises, joint ventures, agencies,
6 institutions or other legal entities providing any form of
7 health care services in this State under this Article.
8     The Illinois Department may require that all dispensers of
9 medical services desiring to participate in the medical
10 assistance program established under this Article disclose,
11 under such terms and conditions as the Illinois Department may
12 by rule establish, all inquiries from clients and attorneys
13 regarding medical bills paid by the Illinois Department, which
14 inquiries could indicate potential existence of claims or liens
15 for the Illinois Department.
16     Enrollment of a vendor that provides non-emergency medical
17 transportation, defined by the Department by rule, shall be
18 conditional for 180 days. During that time, the Department of
19 Healthcare and Family Services may terminate the vendor's
20 eligibility to participate in the medical assistance program
21 without cause. That termination of eligibility is not subject
22 to the Department's hearing process.
23     The Illinois Department shall establish policies,
24 procedures, standards and criteria by rule for the acquisition,
25 repair and replacement of orthotic and prosthetic devices and
26 durable medical equipment. Such rules shall provide, but not be

 

 

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1 limited to, the following services: (1) immediate repair or
2 replacement of such devices by recipients without medical
3 authorization; and (2) rental, lease, purchase or
4 lease-purchase of durable medical equipment in a
5 cost-effective manner, taking into consideration the
6 recipient's medical prognosis, the extent of the recipient's
7 needs, and the requirements and costs for maintaining such
8 equipment. Such rules shall enable a recipient to temporarily
9 acquire and use alternative or substitute devices or equipment
10 pending repairs or replacements of any device or equipment
11 previously authorized for such recipient by the Department.
12     The Department shall execute, relative to the nursing home
13 prescreening project, written inter-agency agreements with the
14 Department of Human Services and the Department on Aging, to
15 effect the following: (i) intake procedures and common
16 eligibility criteria for those persons who are receiving
17 non-institutional services; and (ii) the establishment and
18 development of non-institutional services in areas of the State
19 where they are not currently available or are undeveloped.
20     The Illinois Department shall develop and operate, in
21 cooperation with other State Departments and agencies and in
22 compliance with applicable federal laws and regulations,
23 appropriate and effective systems of health care evaluation and
24 programs for monitoring of utilization of health care services
25 and facilities, as it affects persons eligible for medical
26 assistance under this Code.

 

 

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1     The Illinois Department shall report annually to the
2 General Assembly, no later than the second Friday in April of
3 1979 and each year thereafter, in regard to:
4         (a) actual statistics and trends in utilization of
5     medical services by public aid recipients;
6         (b) actual statistics and trends in the provision of
7     the various medical services by medical vendors;
8         (c) current rate structures and proposed changes in
9     those rate structures for the various medical vendors; and
10         (d) efforts at utilization review and control by the
11     Illinois Department.
12     The period covered by each report shall be the 3 years
13 ending on the June 30 prior to the report. The report shall
14 include suggested legislation for consideration by the General
15 Assembly. The filing of one copy of the report with the
16 Speaker, one copy with the Minority Leader and one copy with
17 the Clerk of the House of Representatives, one copy with the
18 President, one copy with the Minority Leader and one copy with
19 the Secretary of the Senate, one copy with the Legislative
20 Research Unit, and such additional copies with the State
21 Government Report Distribution Center for the General Assembly
22 as is required under paragraph (t) of Section 7 of the State
23 Library Act shall be deemed sufficient to comply with this
24 Section.
25     Notwithstanding any other rulemaking authority that may
26 exist, neither the Governor nor any agency or agency head under

 

 

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1 the jurisdiction of the Governor has any authority to make or
2 promulgate rules to implement or enforce the provisions of this
3 amendatory Act of the 95th General Assembly. If, however, the
4 Governor believes that rules are necessary to implement or
5 enforce the provisions of this amendatory Act of the 95th
6 General Assembly, the Governor may suggest rules to the General
7 Assembly by filing them with the Clerk of the House and the
8 Secretary of the Senate and by requesting that the General
9 Assembly authorize such rulemaking by law, enact those
10 suggested rules into law, or take any other appropriate action
11 in the General Assembly's discretion. Nothing contained in this
12 amendatory Act of the 95th General Assembly shall be
13 interpreted to grant rulemaking authority under any other
14 Illinois statute where such authority is not otherwise
15 explicitly given. For the purposes of this amendatory Act of
16 the 95th General Assembly, "rules" is given the meaning
17 contained in Section 1-70 of the Illinois Administrative
18 Procedure Act, and "agency" and "agency head" are given the
19 meanings contained in Sections 1-20 and 1-25 of the Illinois
20 Administrative Procedure Act to the extent that such
21 definitions apply to agencies or agency heads under the
22 jurisdiction of the Governor.
23 (Source: P.A. 95-331, eff. 8-21-07; 95-520, eff. 8-28-07.)
 
24
Article 10. Breast Cancer Patients'
25
Access To Pain Relief

 

 

 

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1     Section 10-5. The Illinois Insurance Code is amended by
2 adding Section 356g.5-1 as follows:
 
3     (215 ILCS 5/356g.5-1 new)
4     Sec. 356g.5-1. Breast cancer pain medication and therapy. A
5 group or individual policy of accident and health insurance or
6 managed care plan that is amended, delivered, issued, or
7 renewed after the effective date of this amendatory Act of the
8 95th General Assembly must provide coverage for all medically
9 necessary pain medication and pain therapy related to the
10 treatment of breast cancer on the same terms and conditions
11 that are generally applicable to coverage for other conditions.
12 For purposes of this Section, "pain therapy" means pain therapy
13 that is medically based and includes reasonably defined goals,
14 including, but not limited to, stabilizing or reducing pain,
15 with periodic evaluations of the efficacy of the pain therapy
16 against these goals. The provisions of this Section do not
17 apply to short-term travel, accident-only, limited, or
18 specified-disease policies, or to policies or contracts
19 designed for issuance to persons eligible for coverage under
20 Title XVIII of the Social Security Act, known as Medicare, or
21 any other similar coverage under State or federal governmental
22 plans.
23     Notwithstanding any other rulemaking authority that may
24 exist, neither the Governor nor any agency or agency head under

 

 

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1 the jurisdiction of the Governor has any authority to make or
2 promulgate rules to implement or enforce the provisions of this
3 amendatory Act of the 95th General Assembly. If, however, the
4 Governor believes that rules are necessary to implement or
5 enforce the provisions of this amendatory Act of the 95th
6 General Assembly, the Governor may suggest rules to the General
7 Assembly by filing them with the Clerk of the House and the
8 Secretary of the Senate and by requesting that the General
9 Assembly authorize such rulemaking by law, enact those
10 suggested rules into law, or take any other appropriate action
11 in the General Assembly's discretion. Nothing contained in this
12 amendatory Act of the 95th General Assembly shall be
13 interpreted to grant rulemaking authority under any other
14 Illinois statute where such authority is not otherwise
15 explicitly given. For the purposes of this amendatory Act of
16 the 95th General Assembly, "rules" is given the meaning
17 contained in Section 1-70 of the Illinois Administrative
18 Procedure Act, and "agency" and "agency head" are given the
19 meanings contained in Sections 1-20 and 1-25 of the Illinois
20 Administrative Procedure Act to the extent that such
21 definitions apply to agencies or agency heads under the
22 jurisdiction of the Governor.
 
23     Section 10-10. The State Employees Group Insurance Act of
24 1971 is amended by changing Section 6.11 as follows:
 

 

 

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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.5,
8 356g.5-1, 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     Notwithstanding any other rulemaking authority that may
13 exist, neither the Governor nor any agency or agency head under
14 the jurisdiction of the Governor has any authority to make or
15 promulgate rules to implement or enforce the provisions of this
16 amendatory Act of the 95th General Assembly. If, however, the
17 Governor believes that rules are necessary to implement or
18 enforce the provisions of this amendatory Act of the 95th
19 General Assembly, the Governor may suggest rules to the General
20 Assembly by filing them with the Clerk of the House and the
21 Secretary of the Senate and by requesting that the General
22 Assembly authorize such rulemaking by law, enact those
23 suggested rules into law, or take any other appropriate action
24 in the General Assembly's discretion. Nothing contained in this
25 amendatory Act of the 95th General Assembly shall be
26 interpreted to grant rulemaking authority under any other

 

 

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1 Illinois statute where such authority is not otherwise
2 explicitly given. For the purposes of this amendatory Act of
3 the 95th General Assembly, "rules" is given the meaning
4 contained in Section 1-70 of the Illinois Administrative
5 Procedure Act, and "agency" and "agency head" are given the
6 meanings contained in Sections 1-20 and 1-25 of the Illinois
7 Administrative Procedure Act to the extent that such
8 definitions apply to agencies or agency heads under the
9 jurisdiction of the Governor.
10 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
11 95-520, eff. 8-28-07; revised 12-4-07.)
 
12     Section 10-15. The Counties Code is amended by changing
13 Section 5-1069.3 as follows:
 
14     (55 ILCS 5/5-1069.3)
15     Sec. 5-1069.3. Required health benefits. If a county,
16 including a home rule county, is a self-insurer for purposes of
17 providing health insurance coverage for its employees, the
18 coverage shall include coverage for the post-mastectomy care
19 benefits required to be covered by a policy of accident and
20 health insurance under Section 356t and the coverage required
21 under Sections 356g.5, 356g.5-1, 356u, 356w, 356x, 356z.6, and
22 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
23 requirement that health benefits be covered as provided in this
24 Section is an exclusive power and function of the State and is

 

 

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1 a denial and limitation under Article VII, Section 6,
2 subsection (h) of the Illinois Constitution. A home rule county
3 to which this Section applies must comply with every provision
4 of this Section.
5     Notwithstanding any other rulemaking authority that may
6 exist, neither the Governor nor any agency or agency head under
7 the jurisdiction of the Governor has any authority to make or
8 promulgate rules to implement or enforce the provisions of this
9 amendatory Act of the 95th General Assembly. If, however, the
10 Governor believes that rules are necessary to implement or
11 enforce the provisions of this amendatory Act of the 95th
12 General Assembly, the Governor may suggest rules to the General
13 Assembly by filing them with the Clerk of the House and the
14 Secretary of the Senate and by requesting that the General
15 Assembly authorize such rulemaking by law, enact those
16 suggested rules into law, or take any other appropriate action
17 in the General Assembly's discretion. Nothing contained in this
18 amendatory Act of the 95th General Assembly shall be
19 interpreted to grant rulemaking authority under any other
20 Illinois statute where such authority is not otherwise
21 explicitly given. For the purposes of this amendatory Act of
22 the 95th General Assembly, "rules" is given the meaning
23 contained in Section 1-70 of the Illinois Administrative
24 Procedure Act, and "agency" and "agency head" are given the
25 meanings contained in Sections 1-20 and 1-25 of the Illinois
26 Administrative Procedure Act to the extent that such

 

 

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1 definitions apply to agencies or agency heads under the
2 jurisdiction of the Governor.
3 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
4 95-520, eff. 8-28-07; revised 12-4-07.)
 
5     Section 10-20. The Illinois Municipal Code is amended by
6 changing Section 10-4-2.3 as follows:
 
7     (65 ILCS 5/10-4-2.3)
8     Sec. 10-4-2.3. Required health benefits. If a
9 municipality, including a home rule municipality, is a
10 self-insurer for purposes of providing health insurance
11 coverage for its employees, the coverage shall include coverage
12 for the post-mastectomy care benefits required to be covered by
13 a policy of accident and health insurance under Section 356t
14 and the coverage required under Sections 356g.5, 356g.5-1,
15 356u, 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the
16 Illinois Insurance Code. The requirement that health benefits
17 be covered as provided in this is an exclusive power and
18 function of the State and is a denial and limitation under
19 Article VII, Section 6, subsection (h) of the Illinois
20 Constitution. A home rule municipality to which this Section
21 applies must comply with every provision of this Section.
22     Notwithstanding any other rulemaking authority that may
23 exist, neither the Governor nor any agency or agency head under
24 the jurisdiction of the Governor has any authority to make or

 

 

HB5192 Engrossed - 23 - LRB095 17610 DRJ 45972 b

1 promulgate rules to implement or enforce the provisions of this
2 amendatory Act of the 95th General Assembly. If, however, the
3 Governor believes that rules are necessary to implement or
4 enforce the provisions of this amendatory Act of the 95th
5 General Assembly, the Governor may suggest rules to the General
6 Assembly by filing them with the Clerk of the House and the
7 Secretary of the Senate and by requesting that the General
8 Assembly authorize such rulemaking by law, enact those
9 suggested rules into law, or take any other appropriate action
10 in the General Assembly's discretion. Nothing contained in this
11 amendatory Act of the 95th General Assembly shall be
12 interpreted to grant rulemaking authority under any other
13 Illinois statute where such authority is not otherwise
14 explicitly given. For the purposes of this amendatory Act of
15 the 95th General Assembly, "rules" is given the meaning
16 contained in Section 1-70 of the Illinois Administrative
17 Procedure Act, and "agency" and "agency head" are given the
18 meanings contained in Sections 1-20 and 1-25 of the Illinois
19 Administrative Procedure Act to the extent that such
20 definitions apply to agencies or agency heads under the
21 jurisdiction of the Governor.
22 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
23 95-520, eff. 8-28-07; revised 12-4-07.)
 
24     Section 10-25. The School Code is amended by changing
25 Section 10-22.3f as follows:
 

 

 

HB5192 Engrossed - 24 - LRB095 17610 DRJ 45972 b

1     (105 ILCS 5/10-22.3f)
2     Sec. 10-22.3f. Required health benefits. Insurance
3 protection and benefits for employees shall provide the
4 post-mastectomy care benefits required to be covered by a
5 policy of accident and health insurance under Section 356t and
6 the coverage required under Sections 356g.5, 356g.5-1, 356u,
7 356w, 356x, 356z.6, and 356z.9 of the Illinois Insurance Code.
8     Notwithstanding any other rulemaking authority that may
9 exist, neither the Governor nor any agency or agency head under
10 the jurisdiction of the Governor has any authority to make or
11 promulgate rules to implement or enforce the provisions of this
12 amendatory Act of the 95th General Assembly. If, however, the
13 Governor believes that rules are necessary to implement or
14 enforce the provisions of this amendatory Act of the 95th
15 General Assembly, the Governor may suggest rules to the General
16 Assembly by filing them with the Clerk of the House and the
17 Secretary of the Senate and by requesting that the General
18 Assembly authorize such rulemaking by law, enact those
19 suggested rules into law, or take any other appropriate action
20 in the General Assembly's discretion. Nothing contained in this
21 amendatory Act of the 95th General Assembly shall be
22 interpreted to grant rulemaking authority under any other
23 Illinois statute where such authority is not otherwise
24 explicitly given. For the purposes of this amendatory Act of
25 the 95th General Assembly, "rules" is given the meaning

 

 

HB5192 Engrossed - 25 - LRB095 17610 DRJ 45972 b

1 contained in Section 1-70 of the Illinois Administrative
2 Procedure Act, and "agency" and "agency head" are given the
3 meanings contained in Sections 1-20 and 1-25 of the Illinois
4 Administrative Procedure Act to the extent that such
5 definitions apply to agencies or agency heads under the
6 jurisdiction of the Governor.
7 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
8 revised 12-4-07.)
 
9     Section 10-30. The Health Maintenance Organization Act is
10 amended by changing Section 5-3 as follows:
 
11     (215 ILCS 125/5-3)  (from Ch. 111 1/2, par. 1411.2)
12     Sec. 5-3. Insurance Code provisions.
13     (a) Health Maintenance Organizations shall be subject to
14 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
15 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
16 154.6, 154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w,
17 356x, 356y, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
18 356z.10 356z.9, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c,
19 368d, 368e, 370c, 401, 401.1, 402, 403, 403A, 408, 408.2, 409,
20 412, 444, and 444.1, paragraph (c) of subsection (2) of Section
21 367, and Articles IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2,
22 XXV, and XXVI of the Illinois Insurance Code.
23     (b) For purposes of the Illinois Insurance Code, except for
24 Sections 444 and 444.1 and Articles XIII and XIII 1/2, Health

 

 

HB5192 Engrossed - 26 - LRB095 17610 DRJ 45972 b

1 Maintenance Organizations in the following categories are
2 deemed to be "domestic companies":
3         (1) a corporation authorized under the Dental Service
4     Plan Act or the Voluntary Health Services Plans Act;
5         (2) a corporation organized under the laws of this
6     State; or
7         (3) a corporation organized under the laws of another
8     state, 30% or more of the enrollees of which are residents
9     of this State, except a corporation subject to
10     substantially the same requirements in its state of
11     organization as is a "domestic company" under Article VIII
12     1/2 of the Illinois Insurance Code.
13     (c) In considering the merger, consolidation, or other
14 acquisition of control of a Health Maintenance Organization
15 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
16         (1) the Director shall give primary consideration to
17     the continuation of benefits to enrollees and the financial
18     conditions of the acquired Health Maintenance Organization
19     after the merger, consolidation, or other acquisition of
20     control takes effect;
21         (2)(i) the criteria specified in subsection (1)(b) of
22     Section 131.8 of the Illinois Insurance Code shall not
23     apply and (ii) the Director, in making his determination
24     with respect to the merger, consolidation, or other
25     acquisition of control, need not take into account the
26     effect on competition of the merger, consolidation, or

 

 

HB5192 Engrossed - 27 - LRB095 17610 DRJ 45972 b

1     other acquisition of control;
2         (3) the Director shall have the power to require the
3     following information:
4             (A) certification by an independent actuary of the
5         adequacy of the reserves of the Health Maintenance
6         Organization sought to be acquired;
7             (B) pro forma financial statements reflecting the
8         combined balance sheets of the acquiring company and
9         the Health Maintenance Organization sought to be
10         acquired as of the end of the preceding year and as of
11         a date 90 days prior to the acquisition, as well as pro
12         forma financial statements reflecting projected
13         combined operation for a period of 2 years;
14             (C) a pro forma business plan detailing an
15         acquiring party's plans with respect to the operation
16         of the Health Maintenance Organization sought to be
17         acquired for a period of not less than 3 years; and
18             (D) such other information as the Director shall
19         require.
20     (d) The provisions of Article VIII 1/2 of the Illinois
21 Insurance Code and this Section 5-3 shall apply to the sale by
22 any health maintenance organization of greater than 10% of its
23 enrollee population (including without limitation the health
24 maintenance organization's right, title, and interest in and to
25 its health care certificates).
26     (e) In considering any management contract or service

 

 

HB5192 Engrossed - 28 - LRB095 17610 DRJ 45972 b

1 agreement subject to Section 141.1 of the Illinois Insurance
2 Code, the Director (i) shall, in addition to the criteria
3 specified in Section 141.2 of the Illinois Insurance Code, take
4 into account the effect of the management contract or service
5 agreement on the continuation of benefits to enrollees and the
6 financial condition of the health maintenance organization to
7 be managed or serviced, and (ii) need not take into account the
8 effect of the management contract or service agreement on
9 competition.
10     (f) Except for small employer groups as defined in the
11 Small Employer Rating, Renewability and Portability Health
12 Insurance Act and except for medicare supplement policies as
13 defined in Section 363 of the Illinois Insurance Code, a Health
14 Maintenance Organization may by contract agree with a group or
15 other enrollment unit to effect refunds or charge additional
16 premiums under the following terms and conditions:
17         (i) the amount of, and other terms and conditions with
18     respect to, the refund or additional premium are set forth
19     in the group or enrollment unit contract agreed in advance
20     of the period for which a refund is to be paid or
21     additional premium is to be charged (which period shall not
22     be less than one year); and
23         (ii) the amount of the refund or additional premium
24     shall not exceed 20% of the Health Maintenance
25     Organization's profitable or unprofitable experience with
26     respect to the group or other enrollment unit for the

 

 

HB5192 Engrossed - 29 - LRB095 17610 DRJ 45972 b

1     period (and, for purposes of a refund or additional
2     premium, the profitable or unprofitable experience shall
3     be calculated taking into account a pro rata share of the
4     Health Maintenance Organization's administrative and
5     marketing expenses, but shall not include any refund to be
6     made or additional premium to be paid pursuant to this
7     subsection (f)). The Health Maintenance Organization and
8     the group or enrollment unit may agree that the profitable
9     or unprofitable experience may be calculated taking into
10     account the refund period and the immediately preceding 2
11     plan years.
12     The Health Maintenance Organization shall include a
13 statement in the evidence of coverage issued to each enrollee
14 describing the possibility of a refund or additional premium,
15 and upon request of any group or enrollment unit, provide to
16 the group or enrollment unit a description of the method used
17 to calculate (1) the Health Maintenance Organization's
18 profitable experience with respect to the group or enrollment
19 unit and the resulting refund to the group or enrollment unit
20 or (2) the Health Maintenance Organization's unprofitable
21 experience with respect to the group or enrollment unit and the
22 resulting additional premium to be paid by the group or
23 enrollment unit.
24     In no event shall the Illinois Health Maintenance
25 Organization Guaranty Association be liable to pay any
26 contractual obligation of an insolvent organization to pay any

 

 

HB5192 Engrossed - 30 - LRB095 17610 DRJ 45972 b

1 refund authorized under this Section.
2     (g) Notwithstanding any other rulemaking authority that
3 may exist, neither the Governor nor any agency or agency head
4 under the jurisdiction of the Governor has any authority to
5 make or promulgate rules to implement or enforce the provisions
6 of this amendatory Act of the 95th General Assembly. If,
7 however, the Governor believes that rules are necessary to
8 implement or enforce the provisions of this amendatory Act of
9 the 95th General Assembly, the Governor may suggest rules to
10 the General Assembly by filing them with the Clerk of the House
11 and the Secretary of the Senate and by requesting that the
12 General Assembly authorize such rulemaking by law, enact those
13 suggested rules into law, or take any other appropriate action
14 in the General Assembly's discretion. Nothing contained in this
15 amendatory Act of the 95th General Assembly shall be
16 interpreted to grant rulemaking authority under any other
17 Illinois statute where such authority is not otherwise
18 explicitly given. For the purposes of this amendatory Act of
19 the 95th General Assembly, "rules" is given the meaning
20 contained in Section 1-70 of the Illinois Administrative
21 Procedure Act, and "agency" and "agency head" are given the
22 meanings contained in Sections 1-20 and 1-25 of the Illinois
23 Administrative Procedure Act to the extent that such
24 definitions apply to agencies or agency heads under the
25 jurisdiction of the Governor.
26 (Source: P.A. 94-906, eff. 1-1-07; 94-1076, eff. 12-29-06;

 

 

HB5192 Engrossed - 31 - LRB095 17610 DRJ 45972 b

1 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; revised 12-4-07.)
 
2     Section 10-35. The Voluntary Health Services Plans Act is
3 amended by changing Section 10 as follows:
 
4     (215 ILCS 165/10)  (from Ch. 32, par. 604)
5     Sec. 10. Application of Insurance Code provisions. Health
6 services plan corporations and all persons interested therein
7 or dealing therewith shall be subject to the provisions of
8 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
9 149, 155.37, 354, 355.2, 356g.5, 356g.5-1, 356r, 356t, 356u,
10 356v, 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
11 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
12 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
13 and (15) of Section 367 of the Illinois Insurance Code.
14     Notwithstanding any other rulemaking authority that may
15 exist, neither the Governor nor any agency or agency head under
16 the jurisdiction of the Governor has any authority to make or
17 promulgate rules to implement or enforce the provisions of this
18 amendatory Act of the 95th General Assembly. If, however, the
19 Governor believes that rules are necessary to implement or
20 enforce the provisions of this amendatory Act of the 95th
21 General Assembly, the Governor may suggest rules to the General
22 Assembly by filing them with the Clerk of the House and the
23 Secretary of the Senate and by requesting that the General
24 Assembly authorize such rulemaking by law, enact those

 

 

HB5192 Engrossed - 32 - LRB095 17610 DRJ 45972 b

1 suggested rules into law, or take any other appropriate action
2 in the General Assembly's discretion. Nothing contained in this
3 amendatory Act of the 95th General Assembly shall be
4 interpreted to grant rulemaking authority under any other
5 Illinois statute where such authority is not otherwise
6 explicitly given. For the purposes of this amendatory Act of
7 the 95th General Assembly, "rules" is given the meaning
8 contained in Section 1-70 of the Illinois Administrative
9 Procedure Act, and "agency" and "agency head" are given the
10 meanings contained in Sections 1-20 and 1-25 of the Illinois
11 Administrative Procedure Act to the extent that such
12 definitions apply to agencies or agency heads under the
13 jurisdiction of the Governor.
14 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
15 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
16 8-28-07; revised 12-5-07.)
 
17
Article 15. Reducing Financial Barriers To Mammography

 
18     Section 15-5. The Illinois Insurance Code is amended by
19 changing Section 356g as follows:
 
20     (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
21     Sec. 356g. Mammograms; mastectomies.
22     (a) Every insurer shall provide in each group or individual
23 policy, contract, or certificate of insurance issued or renewed

 

 

HB5192 Engrossed - 33 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 34 - LRB095 17610 DRJ 45972 b

1 exposure delivery of less than 1 rad per breast for 2 views of
2 an average size breast. The term also includes digital
3 mammography.
4     (a-5) Coverage as described by subsection (a) shall be
5 provided at no cost to the insured and shall not be applied to
6 an annual or lifetime maximum benefit.
7     (a-10) When health care services are available through
8 contracted providers and a person does not comply with plan
9 provisions specific to the use of contracted providers, the
10 requirements of subsection (a-5) are not applicable. When a
11 person does not comply with plan provisions specific to the use
12 of contracted providers, plan provisions specific to the use of
13 non-contracted providers must be applied without distinction
14 for coverage required by this Section and shall be at least as
15 favorable as for other radiological examinations covered by the
16 policy or contract.
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 Engrossed - 35 - 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 Engrossed - 36 - LRB095 17610 DRJ 45972 b

1     (c) Notwithstanding any other rulemaking authority that
2 may exist, neither the Governor nor any agency or agency head
3 under the jurisdiction of the Governor has any authority to
4 make or promulgate rules to implement or enforce the provisions
5 of this amendatory Act of the 95th General Assembly. If,
6 however, the Governor believes that rules are necessary to
7 implement or enforce the provisions of this amendatory Act of
8 the 95th General Assembly, the Governor may suggest rules to
9 the General Assembly by filing them with the Clerk of the House
10 and the Secretary of the Senate and by requesting that the
11 General Assembly authorize such rulemaking by law, enact those
12 suggested rules into law, or take any other appropriate action
13 in the General Assembly's discretion. Nothing contained in this
14 amendatory Act of the 95th General Assembly shall be
15 interpreted to grant rulemaking authority under any other
16 Illinois statute where such authority is not otherwise
17 explicitly given. For the purposes of this amendatory Act of
18 the 95th General Assembly, "rules" is given the meaning
19 contained in Section 1-70 of the Illinois Administrative
20 Procedure Act, and "agency" and "agency head" are given the
21 meanings contained in Sections 1-20 and 1-25 of the Illinois
22 Administrative Procedure Act to the extent that such
23 definitions apply to agencies or agency heads under the
24 jurisdiction of the Governor.
25 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 

 

 

HB5192 Engrossed - 37 - LRB095 17610 DRJ 45972 b

1     Section 15-10. The State Employees Group Insurance Act of
2 1971 is amended by changing Section 6.11 as follows:
 
3     (5 ILCS 375/6.11)
4     Sec. 6.11. Required health benefits; Illinois Insurance
5 Code requirements. The program of health benefits shall provide
6 the post-mastectomy care benefits required to be covered by a
7 policy of accident and health insurance under Section 356t of
8 the Illinois Insurance Code. The program of health benefits
9 shall provide the coverage required under Sections 356g,
10 356g.5, 356u, 356w, 356x, 356z.2, 356z.4, 356z.6, and 356z.9,
11 and 356z.10 356z.9 of the Illinois Insurance Code. The program
12 of health benefits must comply with Section 155.37 of the
13 Illinois Insurance Code.
14     Notwithstanding any other rulemaking authority that may
15 exist, neither the Governor nor any agency or agency head under
16 the jurisdiction of the Governor has any authority to make or
17 promulgate rules to implement or enforce the provisions of this
18 amendatory Act of the 95th General Assembly. If, however, the
19 Governor believes that rules are necessary to implement or
20 enforce the provisions of this amendatory Act of the 95th
21 General Assembly, the Governor may suggest rules to the General
22 Assembly by filing them with the Clerk of the House and the
23 Secretary of the Senate and by requesting that the General
24 Assembly authorize such rulemaking by law, enact those
25 suggested rules into law, or take any other appropriate action

 

 

HB5192 Engrossed - 38 - LRB095 17610 DRJ 45972 b

1 in the General Assembly's discretion. Nothing contained in this
2 amendatory Act of the 95th General Assembly shall be
3 interpreted to grant rulemaking authority under any other
4 Illinois statute where such authority is not otherwise
5 explicitly given. For the purposes of this amendatory Act of
6 the 95th General Assembly, "rules" is given the meaning
7 contained in Section 1-70 of the Illinois Administrative
8 Procedure Act, and "agency" and "agency head" are given the
9 meanings contained in Sections 1-20 and 1-25 of the Illinois
10 Administrative Procedure Act to the extent that such
11 definitions apply to agencies or agency heads under the
12 jurisdiction of the Governor.
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 15-15. The Counties Code is amended by changing
16 Sections 5-1069 and 5-1069.3 as follows:
 
17     (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
18     Sec. 5-1069. Group life, health, accident, hospital, and
19 medical insurance.
20     (a) The county board of any county may arrange to provide,
21 for the benefit of employees of the county, group life, health,
22 accident, hospital, and medical insurance, or any one or any
23 combination of those types of insurance, or the county board
24 may self-insure, for the benefit of its employees, all or a

 

 

HB5192 Engrossed - 39 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 40 - LRB095 17610 DRJ 45972 b

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.

 

 

HB5192 Engrossed - 41 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 42 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 43 - LRB095 17610 DRJ 45972 b

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     (g) Notwithstanding any other rulemaking authority that
24 may exist, neither the Governor nor any agency or agency head
25 under the jurisdiction of the Governor has any authority to
26 make or promulgate rules to implement or enforce the provisions

 

 

HB5192 Engrossed - 44 - LRB095 17610 DRJ 45972 b

1 of this amendatory Act of the 95th General Assembly. If,
2 however, the Governor believes that rules are necessary to
3 implement or enforce the provisions of this amendatory Act of
4 the 95th General Assembly, the Governor may suggest rules to
5 the General Assembly by filing them with the Clerk of the House
6 and the Secretary of the Senate and by requesting that the
7 General Assembly authorize such rulemaking by law, enact those
8 suggested rules into law, or take any other appropriate action
9 in the General Assembly's discretion. Nothing contained in this
10 amendatory Act of the 95th General Assembly shall be
11 interpreted to grant rulemaking authority under any other
12 Illinois statute where such authority is not otherwise
13 explicitly given. For the purposes of this amendatory Act of
14 the 95th General Assembly, "rules" is given the meaning
15 contained in Section 1-70 of the Illinois Administrative
16 Procedure Act, and "agency" and "agency head" are given the
17 meanings contained in Sections 1-20 and 1-25 of the Illinois
18 Administrative Procedure Act to the extent that such
19 definitions apply to agencies or agency heads under the
20 jurisdiction of the Governor.
21 (Source: P.A. 90-7, eff. 6-10-97; 91-217, eff. 1-1-00.)
 
22     (55 ILCS 5/5-1069.3)
23     Sec. 5-1069.3. Required health benefits. If a county,
24 including a home rule county, is a self-insurer for purposes of
25 providing health insurance coverage for its employees, the

 

 

HB5192 Engrossed - 45 - LRB095 17610 DRJ 45972 b

1 coverage shall include coverage for the post-mastectomy care
2 benefits required to be covered by a policy of accident and
3 health insurance under Section 356t and the coverage required
4 under Sections 356g, 356g.5, 356u, 356w, 356x, 356z.6, and
5 356z.9, and 356z.10 356z.9 of the Illinois Insurance Code. The
6 requirement that health benefits be covered as provided in this
7 Section is an exclusive power and function of the State and is
8 a denial and limitation under Article VII, Section 6,
9 subsection (h) of the Illinois Constitution. A home rule county
10 to which this Section applies must comply with every provision
11 of this Section.
12     Notwithstanding any other rulemaking authority that may
13 exist, neither the Governor nor any agency or agency head under
14 the jurisdiction of the Governor has any authority to make or
15 promulgate rules to implement or enforce the provisions of this
16 amendatory Act of the 95th General Assembly. If, however, the
17 Governor believes that rules are necessary to implement or
18 enforce the provisions of this amendatory Act of the 95th
19 General Assembly, the Governor may suggest rules to the General
20 Assembly by filing them with the Clerk of the House and the
21 Secretary of the Senate and by requesting that the General
22 Assembly authorize such rulemaking by law, enact those
23 suggested rules into law, or take any other appropriate action
24 in the General Assembly's discretion. Nothing contained in this
25 amendatory Act of the 95th General Assembly shall be
26 interpreted to grant rulemaking authority under any other

 

 

HB5192 Engrossed - 46 - LRB095 17610 DRJ 45972 b

1 Illinois statute where such authority is not otherwise
2 explicitly given. For the purposes of this amendatory Act of
3 the 95th General Assembly, "rules" is given the meaning
4 contained in Section 1-70 of the Illinois Administrative
5 Procedure Act, and "agency" and "agency head" are given the
6 meanings contained in Sections 1-20 and 1-25 of the Illinois
7 Administrative Procedure Act to the extent that such
8 definitions apply to agencies or agency heads under the
9 jurisdiction of the Governor.
10 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
11 95-520, eff. 8-28-07; revised 12-4-07.)
 
12     Section 15-20. The Illinois Municipal Code is amended by
13 changing Sections 10-4-2 and 10-4-2.3 as follows:
 
14     (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
15     Sec. 10-4-2. Group insurance.
16     (a) The corporate authorities of any municipality may
17 arrange to provide, for the benefit of employees of the
18 municipality, group life, health, accident, hospital, and
19 medical insurance, or any one or any combination of those types
20 of insurance, and may arrange to provide that insurance for the
21 benefit of the spouses or dependents of those employees. The
22 insurance may include provision for employees or other insured
23 persons who rely on treatment by prayer or spiritual means
24 alone for healing in accordance with the tenets and practice of

 

 

HB5192 Engrossed - 47 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 48 - LRB095 17610 DRJ 45972 b

1 is a self-insurer for purposes of providing health insurance
2 coverage for its employees, the insurance coverage shall
3 include screening by low-dose mammography for all women 35
4 years of age or older for the presence of occult breast cancer
5 unless the municipality elects to provide mammograms itself
6 under Section 10-4-2.1. The coverage shall be as follows:
7         (1) A baseline mammogram for women 35 to 39 years of
8     age.
9         (2) An annual mammogram for women 40 years of age or
10     older.
11         (3) A mammogram at the age and intervals considered
12     medically necessary by the woman's health care provider for
13     women under 40 years of age and having a family history of
14     breast cancer, prior personal history of breast cancer,
15     positive genetic testing, or other risk factors.
16         (4) A comprehensive ultrasound screening of an entire
17     breast or breasts if a mammogram demonstrates
18     heterogeneous or dense breast tissue, when medically
19     necessary as determined by a physician licensed to practice
20     medicine in all of its branches.
21     Those benefits shall be at least as favorable as for other
22 radiological examinations and subject to the same dollar
23 limits, deductibles, and co-insurance factors. For purposes of
24 this subsection, "low-dose mammography" means the x-ray
25 examination of the breast using equipment dedicated
26 specifically for mammography, including the x-ray tube,

 

 

HB5192 Engrossed - 49 - LRB095 17610 DRJ 45972 b

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

 

 

HB5192 Engrossed - 50 - LRB095 17610 DRJ 45972 b

1     mastectomy has been performed;
2         (2) surgery and reconstruction of the other breast to
3     produce a symmetrical appearance; and
4         (3) prostheses and treatment for physical
5     complications at all stages of mastectomy, including
6     lymphedemas.
7 Care shall be determined in consultation with the attending
8 physician and the patient. The offered coverage for prosthetic
9 devices and reconstructive surgery shall be subject to the
10 deductible and coinsurance conditions applied to the
11 mastectomy, and all other terms and conditions applicable to
12 other benefits. When a mastectomy is performed and there is no
13 evidence of malignancy then the offered coverage may be limited
14 to the provision of prosthetic devices and reconstructive
15 surgery to within 2 years after the date of the mastectomy. As
16 used in this Section, "mastectomy" means the removal of all or
17 part of the breast for medically necessary reasons, as
18 determined by a licensed physician.
19     A municipality, including a home rule municipality, that is
20 a self-insurer for purposes of providing health insurance
21 coverage for its employees, may not penalize or reduce or limit
22 the reimbursement of an attending provider or provide
23 incentives (monetary or otherwise) to an attending provider to
24 induce the provider to provide care to an insured in a manner
25 inconsistent with this Section.
26     (d-20) The requirement that mammograms be included in

 

 

HB5192 Engrossed - 51 - LRB095 17610 DRJ 45972 b

1 health insurance coverage as provided in subsections this
2 subsection (d) through (d-15) is an exclusive power and
3 function of the State and is a denial and limitation under
4 Article VII, Section 6, subsection (h) of the Illinois
5 Constitution of home rule municipality powers. A home rule
6 municipality to which subsections (d) through (d-15) apply this
7 subsection applies must comply with every provision of through
8 subsections this subsection.
9     (e) Notwithstanding any other rulemaking authority that
10 may exist, neither the Governor nor any agency or agency head
11 under the jurisdiction of the Governor has any authority to
12 make or promulgate rules to implement or enforce the provisions
13 of this amendatory Act of the 95th General Assembly. If,
14 however, the Governor believes that rules are necessary to
15 implement or enforce the provisions of this amendatory Act of
16 the 95th General Assembly, the Governor may suggest rules to
17 the General Assembly by filing them with the Clerk of the House
18 and the Secretary of the Senate and by requesting that the
19 General Assembly authorize such rulemaking by law, enact those
20 suggested rules into law, or take any other appropriate action
21 in the General Assembly's discretion. Nothing contained in this
22 amendatory Act of the 95th General Assembly shall be
23 interpreted to grant rulemaking authority under any other
24 Illinois statute where such authority is not otherwise
25 explicitly given. For the purposes of this amendatory Act of
26 the 95th General Assembly, "rules" is given the meaning

 

 

HB5192 Engrossed - 52 - LRB095 17610 DRJ 45972 b

1 contained in Section 1-70 of the Illinois Administrative
2 Procedure Act, and "agency" and "agency head" are given the
3 meanings contained in Sections 1-20 and 1-25 of the Illinois
4 Administrative Procedure Act to the extent that such
5 definitions apply to agencies or agency heads under the
6 jurisdiction of the Governor.
7 (Source: P.A. 90-7, eff. 6-10-97; 91-160, eff. 1-1-00.)
 
8     (65 ILCS 5/10-4-2.3)
9     Sec. 10-4-2.3. Required health benefits. If a
10 municipality, including a home rule municipality, is a
11 self-insurer for purposes of providing health insurance
12 coverage for its employees, the coverage shall include coverage
13 for the post-mastectomy care benefits required to be covered by
14 a policy of accident and health insurance under Section 356t
15 and the coverage required under Sections 356g, 356g.5, 356u,
16 356w, 356x, 356z.6, and 356z.9, and 356z.10 356z.9 of the
17 Illinois Insurance Code. The requirement that health benefits
18 be covered as provided in this is an exclusive power and
19 function of the State and is a denial and limitation under
20 Article VII, Section 6, subsection (h) of the Illinois
21 Constitution. A home rule municipality to which this Section
22 applies must comply with every provision of this Section.
23     Notwithstanding any other rulemaking authority that may
24 exist, neither the Governor nor any agency or agency head under
25 the jurisdiction of the Governor has any authority to make or

 

 

HB5192 Engrossed - 53 - LRB095 17610 DRJ 45972 b

1 promulgate rules to implement or enforce the provisions of this
2 amendatory Act of the 95th General Assembly. If, however, the
3 Governor believes that rules are necessary to implement or
4 enforce the provisions of this amendatory Act of the 95th
5 General Assembly, the Governor may suggest rules to the General
6 Assembly by filing them with the Clerk of the House and the
7 Secretary of the Senate and by requesting that the General
8 Assembly authorize such rulemaking by law, enact those
9 suggested rules into law, or take any other appropriate action
10 in the General Assembly's discretion. Nothing contained in this
11 amendatory Act of the 95th General Assembly shall be
12 interpreted to grant rulemaking authority under any other
13 Illinois statute where such authority is not otherwise
14 explicitly given. For the purposes of this amendatory Act of
15 the 95th General Assembly, "rules" is given the meaning
16 contained in Section 1-70 of the Illinois Administrative
17 Procedure Act, and "agency" and "agency head" are given the
18 meanings contained in Sections 1-20 and 1-25 of the Illinois
19 Administrative Procedure Act to the extent that such
20 definitions apply to agencies or agency heads under the
21 jurisdiction of the Governor.
22 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
23 95-520, eff. 8-28-07; revised 12-4-07.)
 
24     Section 15-25. The School Code is amended by changing
25 Section 10-22.3f as follows:
 

 

 

HB5192 Engrossed - 54 - LRB095 17610 DRJ 45972 b

1     (105 ILCS 5/10-22.3f)
2     Sec. 10-22.3f. Required health benefits. Insurance
3 protection and benefits for employees shall provide the
4 post-mastectomy care benefits required to be covered by a
5 policy of accident and health insurance under Section 356t and
6 the coverage required under Sections 356g, 356g.5, 356u, 356w,
7 356x, 356z.6, and 356z.9 of the Illinois Insurance Code.
8     Notwithstanding any other rulemaking authority that may
9 exist, neither the Governor nor any agency or agency head under
10 the jurisdiction of the Governor has any authority to make or
11 promulgate rules to implement or enforce the provisions of this
12 amendatory Act of the 95th General Assembly. If, however, the
13 Governor believes that rules are necessary to implement or
14 enforce the provisions of this amendatory Act of the 95th
15 General Assembly, the Governor may suggest rules to the General
16 Assembly by filing them with the Clerk of the House and the
17 Secretary of the Senate and by requesting that the General
18 Assembly authorize such rulemaking by law, enact those
19 suggested rules into law, or take any other appropriate action
20 in the General Assembly's discretion. Nothing contained in this
21 amendatory Act of the 95th General Assembly shall be
22 interpreted to grant rulemaking authority under any other
23 Illinois statute where such authority is not otherwise
24 explicitly given. For the purposes of this amendatory Act of
25 the 95th General Assembly, "rules" is given the meaning

 

 

HB5192 Engrossed - 55 - LRB095 17610 DRJ 45972 b

1 contained in Section 1-70 of the Illinois Administrative
2 Procedure Act, and "agency" and "agency head" are given the
3 meanings contained in Sections 1-20 and 1-25 of the Illinois
4 Administrative Procedure Act to the extent that such
5 definitions apply to agencies or agency heads under the
6 jurisdiction of the Governor.
7 (Source: P.A. 95-189, eff. 8-16-07; 95-422, eff. 8-24-07;
8 revised 12-4-07.)
 
9     Section 15-30. The Health Maintenance Organization Act is
10 amended by changing Section 4-6.1 as follows:
 
11     (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
12     Sec. 4-6.1. Mammograms; mastectomies.
13     (a) Every contract or evidence of coverage issued by a
14 Health Maintenance Organization for persons who are residents
15 of this State shall contain coverage for screening by low-dose
16 mammography for all women 35 years of age or older for the
17 presence of occult breast cancer. The coverage shall be as
18 follows:
19         (1) A baseline mammogram for women 35 to 39 years of
20     age.
21         (2) An annual mammogram for women 40 years of age or
22     older.
23         (3) A mammogram at the age and intervals considered
24     medically necessary by the woman's health care provider for

 

 

HB5192 Engrossed - 56 - LRB095 17610 DRJ 45972 b

1     women under 40 years of age and having a family history of
2     breast cancer, prior personal history of breast cancer,
3     positive genetic testing, or other risk factors.
4         (4) A comprehensive ultrasound screening of an entire
5     breast or breasts if a mammogram demonstrates
6     heterogeneous or dense breast tissue, when medically
7     necessary as determined by a physician licensed to practice
8     medicine in all of its branches.
9     These benefits shall be at least as favorable as for other
10 radiological examinations and subject to the same dollar
11 limits, deductibles, and co-insurance factors. For purposes of
12 this Section, "low-dose mammography" means the x-ray
13 examination of the breast using equipment dedicated
14 specifically for mammography, including the x-ray tube,
15 filter, compression device, and image receptor, with radiation
16 exposure delivery of less than 1 rad per breast for 2 views of
17 an average size breast. The term also includes digital
18 mammography.
19     (a-5) Coverage as described in subsection (a) shall be
20 provided at no cost to the enrollee and shall not be applied to
21 an annual or lifetime maximum benefit.
22     (b) No contract or evidence of coverage issued by a health
23 maintenance organization that provides for the surgical
24 procedure known as a mastectomy shall be issued, amended,
25 delivered, or renewed in this State on or after the effective
26 date of this amendatory Act of the 92nd General Assembly unless

 

 

HB5192 Engrossed - 57 - LRB095 17610 DRJ 45972 b

1 that coverage also provides for prosthetic devices or
2 reconstructive surgery incident to the mastectomy, providing
3 that the mastectomy is performed after the effective date of
4 this amendatory Act. Coverage for breast reconstruction in
5 connection 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
20 limited to the provision of prosthetic devices and
21 reconstructive surgery to within 2 years after the date of the
22 mastectomy. As used in this Section, "mastectomy" means the
23 removal of all or part of the breast for medically necessary
24 reasons, as determined by a licensed physician.
25     Written notice of the availability of coverage under this
26 Section shall be delivered to the enrollee upon enrollment and

 

 

HB5192 Engrossed - 58 - LRB095 17610 DRJ 45972 b

1 annually thereafter. A health maintenance organization may not
2 deny to an enrollee eligibility, or continued eligibility, to
3 enroll or to renew coverage under the terms of the plan solely
4 for the purpose of avoiding the requirements of this Section. A
5 health maintenance organization may not penalize or reduce or
6 limit the reimbursement of an attending provider or provide
7 incentives (monetary or otherwise) to an attending provider to
8 induce the provider to provide care to an insured in a manner
9 inconsistent with this Section.
10     (c) Notwithstanding any other rulemaking authority that
11 may exist, neither the Governor nor any agency or agency head
12 under the jurisdiction of the Governor has any authority to
13 make or promulgate rules to implement or enforce the provisions
14 of this amendatory Act of the 95th General Assembly. If,
15 however, the Governor believes that rules are necessary to
16 implement or enforce the provisions of this amendatory Act of
17 the 95th General Assembly, the Governor may suggest rules to
18 the General Assembly by filing them with the Clerk of the House
19 and the Secretary of the Senate and by requesting that the
20 General Assembly authorize such rulemaking by law, enact those
21 suggested rules into law, or take any other appropriate action
22 in the General Assembly's discretion. Nothing contained in this
23 amendatory Act of the 95th General Assembly shall be
24 interpreted to grant rulemaking authority under any other
25 Illinois statute where such authority is not otherwise
26 explicitly given. For the purposes of this amendatory Act of

 

 

HB5192 Engrossed - 59 - LRB095 17610 DRJ 45972 b

1 the 95th General Assembly, "rules" is given the meaning
2 contained in Section 1-70 of the Illinois Administrative
3 Procedure Act, and "agency" and "agency head" are given the
4 meanings contained in Sections 1-20 and 1-25 of the Illinois
5 Administrative Procedure Act to the extent that such
6 definitions apply to agencies or agency heads under the
7 jurisdiction of the Governor.
8 (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07.)
 
9     Section 15-35. The Voluntary Health Services Plans Act is
10 amended by changing Section 10 as follows:
 
11     (215 ILCS 165/10)  (from Ch. 32, par. 604)
12     Sec. 10. Application of Insurance Code provisions. Health
13 services plan corporations and all persons interested therein
14 or dealing therewith shall be subject to the provisions of
15 Articles IIA and XII 1/2 and Sections 3.1, 133, 140, 143, 143c,
16 149, 155.37, 354, 355.2, 356g, 356g.5, 356r, 356t, 356u, 356v,
17 356w, 356x, 356y, 356z.1, 356z.2, 356z.4, 356z.5, 356z.6,
18 356z.8, 356z.9, 356z.10 356z.9, 364.01, 367.2, 368a, 401,
19 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
20 and (15) of Section 367 of the Illinois Insurance Code.
21     Notwithstanding any other rulemaking authority that may
22 exist, neither the Governor nor any agency or agency head under
23 the jurisdiction of the Governor has any authority to make or
24 promulgate rules to implement or enforce the provisions of this

 

 

HB5192 Engrossed - 60 - LRB095 17610 DRJ 45972 b

1 amendatory Act of the 95th General Assembly. If, however, the
2 Governor believes that rules are necessary to implement or
3 enforce the provisions of this amendatory Act of the 95th
4 General Assembly, the Governor may suggest rules to the General
5 Assembly by filing them with the Clerk of the House and the
6 Secretary of the Senate and by requesting that the General
7 Assembly authorize such rulemaking by law, enact those
8 suggested rules into law, or take any other appropriate action
9 in the General Assembly's discretion. Nothing contained in this
10 amendatory Act of the 95th General Assembly shall be
11 interpreted to grant rulemaking authority under any other
12 Illinois statute where such authority is not otherwise
13 explicitly given. For the purposes of this amendatory Act of
14 the 95th General Assembly, "rules" is given the meaning
15 contained in Section 1-70 of the Illinois Administrative
16 Procedure Act, and "agency" and "agency head" are given the
17 meanings contained in Sections 1-20 and 1-25 of the Illinois
18 Administrative Procedure Act to the extent that such
19 definitions apply to agencies or agency heads under the
20 jurisdiction of the Governor.
21 (Source: P.A. 94-1076, eff. 12-29-06; 95-189, eff. 8-16-07;
22 95-331, eff. 8-21-07; 95-422, eff. 8-24-07; 95-520, eff.
23 8-28-07; revised 12-5-07.)
 
24     Section 99. Effective date. This Act takes effect upon
25 becoming law.