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90_HB2456 215 ILCS 5/356g from Ch. 73, par. 968g 215 ILCS 125/4-6.1 from Ch. 111 1/2, par. 1408.7 215 ILCS 130/3009 from Ch. 73, par. 1503-9 215 ILCS 165/10 from Ch. 32, par. 604 Amends the Illinois Insurance Code, the Health Maintenance Organization Act, the Limited Health Service Organization Act, and the Voluntary Health Services Plans Act. Provides that coverage under those Acts shall include coverage for a mastectomy and reconstructive breast surgery performed after a mastectomy. Effective immediately. LRB9008442JSmg LRB9008442JSmg 1 AN ACT concerning reconstructive surgery of the breast, 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 Illinois Insurance Code is amended by 6 changing Section 356g as follows: 7 (215 ILCS 5/356g) (from Ch. 73, par. 968g) 8 Sec. 356g. Mammogram; mastectomy. 9 (a) Every insurer shall provide in each group or 10 individual policy, contract, or certificate of insurance 11 issued or renewed for persons who are residents of this 12 State, coverage for screening by low-dose mammography for all 13 women 35 years of age or older for the presence of occult 14 breast cancer within the provisions of the policy, contract, 15 or certificate. The coverage shall be as follows: 16 (1) A baseline mammogram for women 35 to 39 years 17 of age. 18 (2) An annual mammogram for women 40 years of age 19 or older. 20 These benefits shall be at least as favorable as for 21 other radiological examinations and subject to the same 22 dollar limits, deductibles, and co-insurance factors. For 23 purposes of this Section, "low-dose mammography" means the 24 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 27 radiation exposure delivery of less than 1 rad per breast for 28 2 views of an average size breast. 29 (b) No policy of accident or health insurance that 30 provides for the surgical procedure known as a mastectomy 31 shall be issued, amended, delivered or renewed in this State -2- LRB9008442JSmg 1 on or after July 1, 1981, unless coverage is also offered for 2 prosthetic devices or reconstructive surgery incident to the 3 mastectomy, providing that the mastectomy is performed after 4 July 1, 1981. Coverage shall include all stages of 5 reconstruction of the breast on which a partial or total 6 mastectomy has been performed. The coverage shall also 7 include coverage for all stages and revisions of 8 reconstructive breast surgery performed on a nondiseased 9 breast to establish symmetry in the manner determined by the 10 attending physician and the patient to be appropriate after 11 reconstructive surgery on a diseased breast is performed. 12 The offered coverage for prosthetic devices and 13 reconstructive surgery shall be subject to the deductible and 14 coinsurance conditions applied to the mastectomy, and all 15 other terms and conditions applicable to other benefits. 16 When a mastectomy is performed and there is no evidence of 17 malignancy then the offered coverage may be limited to the 18 provision of prosthetic devices and reconstructive surgery to 19 within 2 years after the date of the mastectomy. As used in 20 this Section, "mastectomy" means the removal of all or part 21 of the breast for medically necessary reasons, as determined 22 by a licensed physician. 23 (Source: P.A. 90-7, eff. 6-10-97.) 24 Section 10. The Health Maintenance Organization Act is 25 amended by changing Section 4-6.1 as follows: 26 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7) 27 Sec. 4-6.1. Mammogram; mastectomy. 28 (a) Every contract or evidence of coverage issued by a 29 Health Maintenance Organization for persons who are residents 30 of this State shall contain coverage for screening by 31 low-dose mammography for all women 35 years of age or older 32 for the presence of occult breast cancer. The coverage shall -3- LRB9008442JSmg 1 be as follows: 2 (1) A baseline mammogram for women 35 to 39 years 3 of age. 4 (2) An annual mammogram for women 40 years of age 5 or older. 6 These benefits shall be at least as favorable as for 7 other radiological examinations and subject to the same 8 dollar limits, deductibles, and co-insurance factors. For 9 purposes of this Section, "low-dose mammography" means the 10 x-ray examination of the breast using equipment dedicated 11 specifically for mammography, including the x-ray tube, 12 filter, compression device, and image receptor, with 13 radiation exposure delivery of less than 1 rad per breast for 14 2 views of an average size breast. 15 (b) A contract or evidence of coverage amended, issued, 16 delivered, or renewed for persons who are residents of this 17 State shall provide coverage for all stages of reconstruction 18 of a breast on which a partial or total mastectomy has been 19 performed. The coverage shall also include coverage for all 20 stages and revisions of reconstructive breast surgery 21 performed on a nondiseased breast to establish symmetry in 22 the manner determined by the attending physician and patient 23 to be appropriate after reconstructive surgery on a diseased 24 breast is performed. The offered coverage shall be subject 25 to the deductible and copayment conditions applied to similar 26 surgical services covered under the contract or evidence of 27 coverage. When a mastectomy is performed and there is no 28 evidence of malignancy then the coverage may be limited to 29 the provision or prosthetic devices and reconstructive 30 surgery provided within 2 years after the date of the 31 mastectomy. 32 (Source: P.A. 90-7, eff. 6-10-97; revised 7-29-97.) 33 Section 15. The Limited Health Service Organization Act -4- LRB9008442JSmg 1 is amended by changing Section 3009 as follows: 2 (215 ILCS 130/3009) (from Ch. 73, par. 1503-9) 3 Sec. 3009. Point-of-service limited health service 4 contracts. 5 (a) An LHSO that offers a POS contract: 6 (1) shall include as in-plan covered services all 7 services required by law to be provided by an LHSO; 8 (2) shall provide incentives, which shall include 9 financial incentives, for enrollees to use in-plan 10 covered services; 11 (3) shall not offer services out-of-plan without 12 providing those services on an in-plan basis; 13 (4) may limit or exclude specific types of services 14 from coverage when obtained out-of-plan; 15 (5) may include annual out-of-pocket limits and 16 lifetime maximum benefits allowances for out-of-plan 17 services that are separate from any limits or allowances 18 applied to in-plan services; 19 (6) shall include an annual maximum benefit 20 allowance not to exceed $2,500 per year that is separate 21 from any limits or allowances applied to in-plan 22 services; 23 (7) may limit the groups to which a POS product is 24 offered, however, if a POS product is offered to a group, 25 then it must be offered to all eligible members of that 26 group, when an LHSO provider is available; 27 (8) shall not consider emergency services, 28 authorized referral services, or non-routine services 29 obtained out of the service area to be POS services; and 30 (9) may treat as out-of-plan services those 31 services that an enrollee obtains from a participating 32 provider, but for which the proper authorization was not 33 given by the LHSO. -5- LRB9008442JSmg 1 (b) An LHSO offering a POS contract shall be subject to 2 the following limitations: 3 (1) The LHSO shall not expend in any calendar 4 quarter more than 20% of its total limited health 5 services expenditures for all its members for out-of-plan 6 covered services. 7 (2) If the amount specified in paragraph (1) is 8 exceeded by 2% in a quarter, the LHSO shall effect 9 compliance with paragraph (1) by the end of the following 10 quarter. 11 (3) If compliance with the amount specified in 12 paragraph (1) is not demonstrated in the LHSO's next 13 quarterly report, the LHSO may not offer the POS contract 14 to new groups or include the POS option in the renewal of 15 an existing group until compliance with the amount 16 specified in paragraph (1) is demonstrated or otherwise 17 allowed by the Director. 18 (4) Any LHSO failing, without just cause, to comply 19 with the provisions of this subsection shall be required, 20 after notice and hearing, to pay a penalty of $250 for 21 each day out of compliance, to be recovered by the 22 Director of Insurance. Any penalty recovered shall be 23 paid into the General Revenue Fund. The Director may 24 reduce the penalty if the LHSO demonstrates to the 25 Director that the imposition of the penalty would 26 constitute a financial hardship to the LHSO. 27 (c) Any LHSO that offers a POS product shall: 28 (1) File a quarterly financial statement detailing 29 compliance with the requirements of subsection (b). 30 (2) Track out-of-plan POS utilization separately 31 from in-plan or non-POS out-of-plan emergency care, 32 referral care, and urgent care out of the service area 33 utilization. 34 (3) Record out-of-plan utilization in a manner that -6- LRB9008442JSmg 1 will permit such utilization and cost reporting as the 2 Director may, by regulation, require. 3 (4) Demonstrate to the Director's satisfaction that 4 the LHSO has the fiscal, administrative, and marketing 5 capacity to control its POS enrollment, utilization, and 6 costs so as not to jeopardize the financial security of 7 the LHSO. 8 (5) Maintain the deposit required by subsection (b) 9 of Section 2006 in addition to any other deposit required 10 under this Act. 11 (d) An LHSO shall not issue a POS contract until it has 12 filed and had approved by the Director a plan to comply with 13 the provisions of this Section. The compliance plan shall at 14 a minimum include provisions demonstrating that the LHSO will 15 do all of the following: 16 (1) Design the benefit levels and conditions of 17 coverage for in-plan covered services and out-of-plan 18 covered services as required by this Article. 19 (2) Provide or arrange for the provision of 20 adequate systems to: 21 (A) process and pay claims for all out-of-plan 22 covered services; 23 (B) meet the requirements for a POS contract 24 set forth in this Section and any additional 25 requirements that may be set forth by the Director; 26 and 27 (C) generate accurate data and financial and 28 regulatory reports on a timely basis so that the 29 Department can evaluate the LHSO's experience with 30 the POS contract and monitor compliance with POS 31 contract provisions. 32 (3) Comply initially and on an ongoing basis with 33 the requirements of subsections (b) and (c). 34 (e) A limited health service organization shall comply -7- LRB9008442JSmg 1 with the provisions of Section 356g of the Illinois Insurance 2 Code. 3 (Source: P.A. 87-1079; 88-667, eff. 9-16-94.) 4 Section 20. The Voluntary Health Services Plans Act is 5 amended by changing Section 10 as follows: 6 (215 ILCS 165/10) (from Ch. 32, par. 604) 7 Sec. 10. Application of Insurance Code provisions. 8 Health services plan corporations and all persons interested 9 therein or dealing therewith shall be subject to the 10 provisions of Article XII 1/2 and Sections 3.1, 133, 140, 11 143, 143c, 149, 354, 355.2, 356g, 356r, 356t, 356u, 356v, 12 367.2, 401, 401.1, 402, 403, 403A, 408, 408.2, and 412, and 13 paragraphs (7) and (15) of Section 367 of the Illinois 14 Insurance Code. 15 (Source: P.A. 89-514, eff. 7-17-96; 90-7, eff. 6-10-97; 16 90-25, eff. 1-1-98; revised 10-14-97.) 17 Section 99. Effective date. This Act takes effect upon 18 becoming law.
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