Full Text of SB0054 99th General Assembly
SB0054 99TH GENERAL ASSEMBLY |
| | 99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016 SB0054 Introduced 1/15/2015, by Sen. John G. Mulroe SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/356g | from Ch. 73, par. 968g | 215 ILCS 125/4-6.1 | from Ch. 111 1/2, par. 1408.7 |
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Amends the Illinois Insurance Code and the Health Maintenance Organization Act. Includes breast tomosynthesis in the definition of "low-dose mammography".
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 356g as follows:
| 6 | | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| 7 | | Sec. 356g. Mammograms; mastectomies.
| 8 | | (a) Every insurer shall provide in each group or individual
| 9 | | policy, contract, or certificate of insurance issued or renewed | 10 | | for persons
who are residents of this State, coverage for | 11 | | screening by low-dose
mammography for all women 35 years of age | 12 | | or older for the presence of
occult breast cancer within the | 13 | | provisions of the policy, contract, or
certificate. The | 14 | | coverage shall be as follows:
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(1) A baseline mammogram for women 35 to 39 years of | 16 | | age.
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(2) An annual mammogram for women 40 years of age or | 18 | | older.
| 19 | | (3) A mammogram at the age and intervals considered | 20 | | medically necessary by the woman's health care provider for | 21 | | women under 40 years of age and having a family history of | 22 | | breast cancer, prior personal history of breast cancer, | 23 | | positive genetic testing, or other risk factors.
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| 1 | | (4) A comprehensive ultrasound screening of an entire | 2 | | breast or breasts if a mammogram demonstrates | 3 | | heterogeneous or dense breast tissue, when medically | 4 | | necessary as determined by a physician licensed to practice | 5 | | medicine in all of its branches.
| 6 | | For purposes of this Section, "low-dose mammography"
means | 7 | | the x-ray examination of the breast using equipment dedicated
| 8 | | specifically for mammography, including the x-ray tube, | 9 | | filter, compression
device, and image receptor, with radiation | 10 | | exposure delivery of less than
1 rad per breast for 2 views of | 11 | | an average size breast. The term also includes digital | 12 | | mammography and breast tomosynthesis. As used in this Section, | 13 | | the term "breast tomosynthesis" means a radiologic procedure | 14 | | that involves the acquisition of projection images over the | 15 | | stationary breast to produce cross-sectional digital | 16 | | three-dimensional images of the breast .
| 17 | | (a-5) Coverage as described by subsection (a) shall be | 18 | | provided at no cost to the insured and shall not be applied to | 19 | | an annual or lifetime maximum benefit. | 20 | | (a-10) When health care services are available through | 21 | | contracted providers and a person does not comply with plan | 22 | | provisions specific to the use of contracted providers, the | 23 | | requirements of subsection (a-5) are not applicable. When a | 24 | | person does not comply with plan provisions specific to the use | 25 | | of contracted providers, plan provisions specific to the use of | 26 | | non-contracted providers must be applied without distinction |
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| 1 | | for coverage required by this Section and shall be at least as | 2 | | favorable as for other radiological examinations covered by the | 3 | | policy or contract. | 4 | | (b) No policy of accident or health insurance that provides | 5 | | for
the surgical procedure known as a mastectomy shall be | 6 | | issued, amended,
delivered, or renewed in this State unless
| 7 | | that coverage also provides for prosthetic devices
or | 8 | | reconstructive surgery
incident to the mastectomy.
Coverage | 9 | | for breast reconstruction in connection with a mastectomy shall
| 10 | | include:
| 11 | | (1) reconstruction of the breast upon which the | 12 | | mastectomy has been
performed;
| 13 | | (2) surgery and reconstruction of the other breast to | 14 | | produce a
symmetrical appearance; and
| 15 | | (3) prostheses and treatment for physical | 16 | | complications at all stages of
mastectomy, including | 17 | | lymphedemas.
| 18 | | Care shall be determined in consultation with the attending | 19 | | physician and the
patient.
The offered coverage for prosthetic | 20 | | devices and
reconstructive surgery shall be subject to the | 21 | | deductible and coinsurance
conditions applied to the | 22 | | mastectomy, and all other terms and conditions
applicable to | 23 | | other benefits. When a mastectomy is performed and there is
no | 24 | | evidence of malignancy then the offered coverage may be limited | 25 | | to the
provision of prosthetic devices and reconstructive | 26 | | surgery to within 2
years after the date of the mastectomy. As |
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| 1 | | used in this Section,
"mastectomy" means the removal of all or | 2 | | part of the breast for medically
necessary reasons, as | 3 | | determined by a licensed physician.
| 4 | | Written notice of the availability of coverage under this | 5 | | Section shall be
delivered to the insured upon enrollment and | 6 | | annually thereafter. An insurer
may not deny to an insured | 7 | | eligibility, or continued eligibility, to enroll or
to renew | 8 | | coverage under the terms of the plan solely for the purpose of
| 9 | | avoiding the requirements of this Section. An insurer may not | 10 | | penalize or
reduce or
limit the reimbursement of an attending | 11 | | provider or provide incentives
(monetary or otherwise) to an | 12 | | attending provider to induce the provider to
provide care to an | 13 | | insured in a manner inconsistent with this Section.
| 14 | | (c) Rulemaking authority to implement this amendatory Act | 15 | | of the 95th General Assembly, if any, is conditioned on the | 16 | | rules being adopted in accordance with all provisions of the | 17 | | Illinois Administrative Procedure Act and all rules and | 18 | | procedures of the Joint Committee on Administrative Rules; any | 19 | | purported rule not so adopted, for whatever reason, is | 20 | | unauthorized. | 21 | | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 22 | | 95-1045, eff. 3-27-09.)
| 23 | | Section 10. The Health Maintenance Organization Act is | 24 | | amended by changing Section 4-6.1 as follows:
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| 1 | | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| 2 | | Sec. 4-6.1. Mammograms; mastectomies.
| 3 | | (a) Every contract or evidence of coverage
issued by a | 4 | | Health Maintenance Organization for persons who are residents | 5 | | of
this State shall contain coverage for screening by low-dose | 6 | | mammography
for all women 35 years of age or older for the | 7 | | presence of occult breast
cancer. The coverage shall be as | 8 | | follows:
| 9 | | (1) A baseline mammogram for women 35 to 39 years of | 10 | | age.
| 11 | | (2) An annual mammogram for women 40 years of age or | 12 | | older.
| 13 | | (3) A mammogram at the age and intervals considered | 14 | | medically necessary by the woman's health care provider for | 15 | | women under 40 years of age and having a family history of | 16 | | breast cancer, prior personal history of breast cancer, | 17 | | positive genetic testing, or other risk factors. | 18 | | (4) A comprehensive ultrasound screening of an entire | 19 | | breast or breasts if a mammogram demonstrates | 20 | | heterogeneous or dense breast tissue, when medically | 21 | | necessary as determined by a physician licensed to practice | 22 | | medicine in all of its branches.
| 23 | | For purposes of this Section, "low-dose mammography"
means | 24 | | the x-ray 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 |
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| 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 and breast tomosynthesis. As used in this Section, | 4 | | the term "breast tomosynthesis" means a radiologic procedure | 5 | | that involves the acquisition of projection images over the | 6 | | stationary breast to produce cross-sectional digital | 7 | | three-dimensional images of the breast .
| 8 | | (a-5) Coverage as described in subsection (a) shall be | 9 | | provided at no cost to the enrollee and shall not be applied to | 10 | | an annual or lifetime maximum benefit. | 11 | | (b) No contract or evidence of coverage issued by a health | 12 | | maintenance
organization that provides for the
surgical | 13 | | procedure known as a mastectomy shall be issued, amended, | 14 | | delivered,
or renewed in this State on or after the effective | 15 | | date of this amendatory Act
of the 92nd General Assembly unless | 16 | | that coverage also provides for prosthetic
devices or | 17 | | reconstructive surgery incident to the mastectomy, providing | 18 | | that
the mastectomy is performed after the effective date of | 19 | | this amendatory Act.
Coverage for breast reconstruction in | 20 | | connection
with a mastectomy shall
include:
| 21 | | (1) reconstruction of the breast upon which the | 22 | | mastectomy has been
performed;
| 23 | | (2) surgery and reconstruction of the other breast to | 24 | | produce a
symmetrical appearance; and
| 25 | | (3) prostheses and treatment for physical | 26 | | complications at all stages of
mastectomy, including |
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| 1 | | lymphedemas.
| 2 | | Care shall be determined in consultation with the attending | 3 | | physician and the
patient.
The offered coverage for prosthetic | 4 | | devices and
reconstructive surgery shall be subject to the | 5 | | deductible and coinsurance
conditions applied to the | 6 | | mastectomy and all other terms and conditions
applicable to | 7 | | other benefits. When a mastectomy is performed and there is
no | 8 | | evidence of malignancy, then the offered coverage may be | 9 | | limited to the
provision of prosthetic devices and | 10 | | reconstructive surgery to within 2
years after the date of the | 11 | | mastectomy. As used in this Section,
"mastectomy" means the | 12 | | removal of all or part of the breast for medically
necessary | 13 | | reasons, as determined by a licensed physician.
| 14 | | Written notice of the availability of coverage under this | 15 | | Section shall be
delivered to the enrollee upon enrollment and | 16 | | annually thereafter. A
health maintenance organization may not | 17 | | deny to an enrollee eligibility, or
continued eligibility, to | 18 | | enroll or
to renew coverage under the terms of the plan solely | 19 | | for the purpose of
avoiding the requirements of this Section. A | 20 | | health maintenance organization
may not penalize or
reduce or
| 21 | | limit the reimbursement of an attending provider or provide | 22 | | incentives
(monetary or otherwise) to an attending provider to | 23 | | induce the provider to
provide care to an insured in a manner | 24 | | inconsistent with this Section.
| 25 | | (c) Rulemaking authority to implement this amendatory Act | 26 | | of the 95th General Assembly, if any, is conditioned on the |
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| 1 | | rules being adopted in accordance with all provisions of the | 2 | | Illinois Administrative Procedure Act and all rules and | 3 | | procedures of the Joint Committee on Administrative Rules; any | 4 | | purported rule not so adopted, for whatever reason, is | 5 | | unauthorized. | 6 | | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 7 | | 95-1045, eff. 3-27-09.)
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