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90_HB0107eng
5 ILCS 375/6.9 new
30 ILCS 805/8.21 new
55 ILCS 5/5-1069.3 new
65 ILCS 5/10-4-2.3 new
105 ILCS 5/10-22.3f new
215 ILCS 5/356t new
215 ILCS 105/8.7 new
215 ILCS 125/4-6.5 new
215 ILCS 165/10 from Ch. 32, par. 604
305 ILCS 5/5-16.8 new
Amends the State Employees Group Insurance Law of 1971,
Counties Code, Illinois Municipal Code, School Code, Illinois
Insurance Code, Health Maintenance Organization Act,
Comprehensive Health Insurance Plan Act, Voluntary Health
Services Plans Act, and Illinois Public Aid Code. Provides
that health care benefits under those Acts and under managed
care plans must provide for a minimum of 96 hours of
inpatient care following a mastectomy. Allows a shorter
inpatient care period if certain criteria are met. Prohibits
penalizing physicians for authorizing inpatient care as
required by law. Amends the State Mandates Act to provide
that reimbursement for post-mastectomy care benefits is not
required under that Act. Effective June 1, 1997.
LRB9000924JSgc
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1 AN ACT concerning medical coverage for mastectomies,
2 amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The State Employees Group Insurance Act of
6 1971 is amended by adding Section 6.9 as follows:
7 (5 ILCS 375/6.9 new)
8 Sec. 6.9. Post-mastectomy care. The program of health
9 benefits shall provide the post-mastectomy care benefits
10 required to be covered by a policy of accident and health
11 insurance under Section 356t of the Illinois Insurance Code.
12 Section 10. The State Mandates Act is amended by adding
13 Section 8.21 as follows:
14 (30 ILCS 805/8.21 new)
15 Sec. 8.21. Exempt mandate. Notwithstanding Sections 6
16 and 8 of this Act, no reimbursement by the State is required
17 for the implementation of any mandate created by this
18 amendatory Act of 1997.
19 Section 15. The Counties Code is amended by adding
20 Section 5-1069.3 as follows:
21 (55 ILCS 5/5-1069.3 new)
22 Sec. 5-1069.3. Post-mastectomy care. If a county,
23 including a home rule county, is a self-insurer for purposes
24 of providing health insurance coverage for its employees, the
25 coverage shall include coverage for the post-mastectomy care
26 benefits required to be covered by a policy of accident and
27 health insurance under Section 356t of the Illinois Insurance
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1 Code. The requirement that post-mastectomy care be covered
2 as provided in this Section 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. A home rule county to which this Section
6 applies must comply with every provision of this Section.
7 Section 20. The Illinois Municipal Code is amended by
8 adding Section 10-4-2.3 as follows:
9 (65 ILCS 5/10-4-2.3 new)
10 Sec. 10-4-2.3. Post-mastectomy care. If a municipality,
11 including a home rule municipality, is a self-insurer for
12 purposes of providing health insurance coverage for its
13 employees, the coverage shall include coverage for the
14 post-mastectomy care benefits required to be covered by a
15 policy of accident and health insurance under Section 356t of
16 the Illinois Insurance Code. The requirement that
17 post-mastectomy care be covered as provided in this Section
18 is an exclusive power and function of the State and is a
19 denial and limitation under Article VII, Section 6,
20 subsection (h) of the Illinois Constitution. A home rule
21 municipality to which this Section applies must comply with
22 every provision of this Section.
23 Section 25. The School Code is amended by adding Section
24 10-22.3f as follows:
25 (105 ILCS 5/10-22.3f new)
26 Sec. 10-22.3f. Post-mastectomy care. Insurance
27 protection and benefits for employees shall provide the
28 post-mastectomy care benefits required to be covered by a
29 policy of accident and health insurance under Section 356t of
30 the Illinois Insurance Code.
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1 Section 30. The Illinois Insurance Code is amended by
2 adding Section 356t as follows:
3 (215 ILCS 5/356t new)
4 Sec. 356t. Post-mastectomy care.
5 (a) An individual or group policy of accident and health
6 insurance or managed care plan that provides surgical
7 coverage and is amended, delivered, issued, or renewed after
8 the effective date of this amendatory Act of 1997 shall
9 provide coverage for a minimum of 96 hours of inpatient care
10 following a mastectomy, except as otherwise provided in this
11 Section.
12 (b) A shorter length of hospital inpatient stay for
13 services related to a mastectomy may be provided if the
14 attending physician determines in accordance with the
15 protocols and guidelines developed by the American College of
16 Surgeons or other appropriate national medical speciality
17 society deemed appropriate by the attending physician that
18 the patient meets the appropriate guidelines for that length
19 of stay based upon evaluation of the patient and the coverage
20 for and availability of a post-discharge physician office
21 visit or in-home nurse visit to verify the condition of the
22 patient in the first 48 hours after discharge.
23 (c) An issuer of an individual or group policy of
24 accident and health insurance or managed care plan may not
25 (i) engage in any activities or provide incentives (monetary
26 or otherwise) to hospitals, insureds, enrollees, or
27 physicians to induce the provision of care to an individual
28 insured or enrollee in a manner inconsistent with this
29 Section or (ii) restrict benefits for any portions of a
30 period within a hospital length of stay required under
31 subsection (a) in a manner that is less favorable than the
32 benefits provided for any preceding portion of the stay.
33 Nothing in this subsection shall be construed as
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1 preventing a plan or issuer from imposing deductibles,
2 coinsurance, or other cost-sharing in relation to benefits
3 for hospital lengths of stay in connection with surgical care
4 for a person under the policy or plan, except that the
5 coinsurance or other cost-sharing for any portion of a period
6 within a hospital length of stay required under subsection
7 (a) may not be greater than the coinsurance or cost-sharing
8 for any preceding portion of the stay.
9 (d) For the purposes of this Section the following terms
10 are defined:
11 (1) "Attending physician" means a physician
12 licensed to practice medicine in all its branches
13 providing care to the patient.
14 (2) "Managed care plan" means a plan that
15 establishes, operates, or maintains a network of health
16 care providers that have entered into agreements with the
17 plan to provide health care services to enrollees where
18 the plan has the ultimate and direct contractual
19 obligation to the enrollee to arrange for the provision
20 of or pay for services through:
21 (A) organizational arrangements for ongoing
22 quality assurance, utilization review programs, or
23 dispute resolution; or
24 (B) financial incentives for persons enrolled
25 in the plan to use the participating providers and
26 procedures covered by the plan.
27 A managed care plan may be established or operated
28 by any entity including a licensed insurance company,
29 hospital or medical service plan, health maintenance
30 organization, limited health service organization,
31 preferred provider organization, third party
32 administrator, or an employer or employee organization.
33 (e) The insurer or plan shall inform all insureds or
34 enrollees in writing of the right to this minimum coverage
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1 under this Section as part of the insurer's or plan's regular
2 notice of coverage to insureds or enrollees and at the time
3 the insured or enrollee is admitted to a hospital for
4 procedures subject to this Section.
5 Section 35. The Comprehensive Health Insurance Plan Act
6 is amended by adding Section 8.7 as follows:
7 (215 ILCS 105/8.7 new)
8 Sec. 8.7. Post-mastectomy care. The plan is subject to
9 the provisions of Section 356t of the Illinois Insurance
10 Code.
11 Section 40. The Health Maintenance Organization Act is
12 amended by adding Section 4-6.5 as follows:
13 (215 ILCS 125/4-6.5 new)
14 Sec. 4-6.5. Post-mastectomy care. A health maintenance
15 organization is subject to the provisions of Section 356t of
16 the Illinois Insurance Code.
17 Section 42. The Limited Health Service Organization Act
18 is amended by changing Section 4003 as follows:
19 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
20 Sec. 4003. Illinois Insurance Code provisions. Limited
21 health service organizations shall be subject to the
22 provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
23 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
24 154.6, 154.7, 154.8, 155.04, 355.2, 356t, 401, 401.1, 402,
25 403, 403A, 408, 408.2, and 412, and Articles VIII 1/2, XII,
26 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
27 Code. For purposes of the Illinois Insurance Code, except
28 for Articles XIII and XIII 1/2, limited health service
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1 organizations in the following categories are deemed to be
2 domestic companies:
3 (1) a corporation under the laws of this State; or
4 (2) a corporation organized under the laws of
5 another state, 30% of more of the enrollees of which are
6 residents of this State, except a corporation subject to
7 substantially the same requirements in its state of
8 organization as is a domestic company under Article VIII
9 1/2 of the Illinois Insurance Code.
10 (Source: P.A. 86-600; 87-587; 87-1090.)
11 Section 45. The Voluntary Health Services Plans Act is
12 amended by changing Section 10 as follows:
13 (215 ILCS 165/10) (from Ch. 32, par. 604)
14 Sec. 10. Application of Insurance Code provisions.
15 Health services plan corporations and all persons interested
16 therein or dealing therewith shall be subject to the
17 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
18 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
19 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
20 (15) of Section 367 of the Illinois Insurance Code.
21 (Source: P.A. 89-514, eff. 7-17-96.)
22 Section 50. The Illinois Public Aid Code is amended by
23 adding Section 5-16.8 as follows:
24 (305 ILCS 5/5-16.8 new)
25 Sec. 5-16.8. Post-mastectomy care. The medical
26 assistance program shall provide the post-mastectomy care
27 benefits required to be covered by a policy of accident and
28 health insurance under Section 356t of the Illinois Insurance
29 Code.
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1 Section 99. Effective date. This Act takes effect June
2 1, 1997.