Illinois General Assembly - Illinois Compiled Statutes

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215 ILCS 125/4-6.1

    (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
    (Text of Section before amendment by P.A. 103-808)
    Sec. 4-6.1. Mammograms; mastectomies.

(a) Every contract or evidence of coverage
issued by a Health Maintenance Organization for persons who are residents of
this State shall contain coverage for screening by low-dose mammography
for all women 35 years of age or older for the presence of occult breast
cancer.  The coverage shall be as follows:

(1) A baseline mammogram for women 35 to 39 years of

age.

(2) An annual mammogram for women 40 years of age or

older.

(3) A mammogram at the age and intervals considered

medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.

(4) For an individual or group policy of accident and

health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.

(5) For an individual or group policy of accident and

health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 101st General Assembly, a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant.

A policy subject to this subsection shall not impose a deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided; except that this sentence does not apply to coverage of diagnostic mammograms to the extent such coverage would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. 223).

For purposes of this Section:

"Diagnostic
mammogram" means a mammogram obtained using diagnostic mammography.

"Diagnostic
mammography" means a method of screening that is designed to
evaluate an abnormality in a breast, including an abnormality seen
or suspected on a screening mammogram or a subjective or objective
abnormality otherwise detected in the breast.

"Low-dose mammography"
means the x-ray examination of the breast using equipment dedicated
specifically for mammography, including the x-ray tube, filter, compression
device, and image receptor, with radiation exposure delivery of less than 1
rad per breast for 2 views of an average size breast. The term also includes digital mammography and includes breast tomosynthesis.

"Breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast.

If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this subsection, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this subsection.

(a-5) Coverage as described in subsection (a) shall be provided at no cost to the enrollee and shall not be applied to an annual or lifetime maximum benefit.

(b) No contract or evidence of coverage issued by a health maintenance
organization that provides for the
surgical procedure known as a mastectomy shall be issued, amended, delivered,
or renewed in this State on or after the effective date of this amendatory Act
of the 92nd General Assembly unless that coverage also provides for prosthetic
devices or reconstructive surgery incident to the mastectomy, providing that
the mastectomy is performed after the effective date of this amendatory Act.
Coverage for breast reconstruction in connection
with a mastectomy shall
include:

(1) reconstruction of the breast upon which the

mastectomy has been performed;

(2) surgery and reconstruction of the other breast to

produce a symmetrical appearance; and

(3) prostheses and treatment for physical

complications at all stages of mastectomy, including lymphedemas.

Care shall be determined in consultation with the attending physician and the
patient.
The offered coverage for prosthetic devices and
reconstructive surgery shall be subject to the deductible and coinsurance
conditions applied to the mastectomy and all other terms and conditions
applicable to other benefits.  When a mastectomy is performed and there is
no evidence of malignancy, then the offered coverage may be limited to the
provision of prosthetic devices and reconstructive surgery to within 2
years after the date of the mastectomy. As used in this Section,
"mastectomy" means the removal of all or part of the breast for medically
necessary reasons, as determined by a licensed physician.

Written notice of the availability of coverage under this Section shall be
delivered to the enrollee upon enrollment and annually thereafter.  A
health maintenance organization may not deny to an enrollee eligibility, or
continued eligibility, to enroll or
to renew coverage under the terms of the plan solely for the purpose of
avoiding the requirements of this Section.  A health maintenance organization
may not penalize or
reduce or
limit the reimbursement of an attending provider or provide incentives
(monetary or otherwise) to an attending provider to induce the provider to
provide care to an insured in a manner inconsistent with this Section.

(c) Rulemaking authority to implement this amendatory Act of the 95th General Assembly, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 100-395, eff. 1-1-18; 101-580, eff. 1-1-20.)

    (Text of Section after amendment by P.A. 103-808)
    Sec. 4-6.1. Mammograms; mastectomies.

(a) Every contract or evidence of coverage issued by a Health Maintenance Organization for persons who are residents of this State shall contain coverage for screening by low-dose mammography for all patients 35 years of age or older for the presence of occult breast cancer. The coverage shall be as follows:

(1) A baseline mammogram for patients 35 to 39 years

of age.

(2) An annual mammogram for patients 40 years of age

or older.

(3) A mammogram at the age and intervals considered

medically necessary by the patient's health care provider for patients under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.

(4) For an individual or group policy of accident and

health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2020 (the effective date of Public Act 101-580) and before the effective date of this amendatory Act of the 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches.

(4.3) For an individual or group policy of accident

and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly, a comprehensive ultrasound screening and MRI of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.

(4.5) For a group policy of accident and health

insurance that is amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 103rd General Assembly, molecular breast imaging (MBI) of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue or when medically necessary as determined by a physician licensed to practice medicine in all of its branches, advanced practice registered nurse, or physician assistant.