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91_SB1955
LRB9113635JSpc
1 AN ACT concerning insurance coverage relating to
2 mastectomies and mammograms.
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. Mammograms; mastectomies.
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
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1 on or after July 1, 1981, unless that coverage is also
2 provides offered for prosthetic devices or reconstructive
3 surgery incident to the mastectomy, providing that the
4 mastectomy is performed after July 1, 1981. Coverage for
5 breast reconstruction in connection with a mastectomy shall
6 include:
7 (1) reconstruction of the breast upon which the
8 mastectomy has been performed;
9 (2) surgery and reconstruction of the other breast
10 to produce a symmetrical appearance; and
11 (3) prostheses and treatment for physical
12 complications at all stages of mastectomy, including
13 lymphedemas.
14 Care shall be determined in consultation with the attending
15 physician and the patient. The offered coverage for
16 prosthetic devices and reconstructive surgery shall be
17 subject to the deductible and coinsurance conditions applied
18 to the mastectomy, and all other terms and conditions
19 applicable to other benefits. When a mastectomy is performed
20 and there is no evidence of malignancy then the offered
21 coverage may be limited to the provision of prosthetic
22 devices and reconstructive surgery to within 2 years after
23 the date of the mastectomy. As used in this Section,
24 "mastectomy" means the removal of all or part of the breast
25 for medically necessary reasons, as determined by a licensed
26 physician.
27 Written notice of the availability of coverage under this
28 Section shall be delivered to the insured upon enrollment and
29 annually thereafter. An insurer may not deny to an insured
30 eligibility, or continued eligibility, to enroll or to renew
31 coverage under the terms of the plan solely for the purpose
32 of avoiding the requirements of this Section. An insurer may
33 not penalize or reduce or limit the reimbursement of an
34 attending provider or provide incentives (monetary or
-3- LRB9113635JSpc
1 otherwise) to an attending provider to induce the provider to
2 provide care to an insured in a manner inconsistent with this
3 Section.
4 (Source: P.A. 90-7, eff. 6-10-97.)
5 Section 10. The Health Maintenance Organization Act is
6 amended by changing Section 4-6.1 as follows:
7 (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
8 Sec. 4-6.1. Mammograms; mastectomies.
9 (a) Every contract or evidence of coverage issued by a
10 Health Maintenance Organization for persons who are residents
11 of this State shall contain coverage for screening by
12 low-dose mammography for all women 35 years of age or older
13 for the presence of occult breast cancer. The coverage shall
14 be as follows:
15 (1) A baseline mammogram for women 35 to 39 years
16 of age.
17 (2) An annual mammogram for women 40 years of age
18 or older.
19 These benefits shall be at least as favorable as for
20 other radiological examinations and subject to the same
21 dollar limits, deductibles, and co-insurance factors. For
22 purposes of this Section, "low-dose mammography" means the
23 x-ray examination of the breast using equipment dedicated
24 specifically for mammography, including the x-ray tube,
25 filter, compression device, and image receptor, with
26 radiation exposure delivery of less than 1 rad per breast for
27 2 views of an average size breast.
28 (b) No contract or evidence of coverage issued by a
29 health maintenance organization for persons who are residents
30 of this State that provides for the surgical procedure known
31 as a mastectomy shall be issued, amended, delivered, or
32 renewed in this State on or after the effective date of this
-4- LRB9113635JSpc
1 amendatory Act of the 91st General Assembly unless that
2 coverage also provides for prosthetic devices or
3 reconstructive surgery incident to the mastectomy, providing
4 that the mastectomy is performed after the effective date of
5 this amendatory Act of the 91st General Assembly. Coverage
6 for breast reconstruction in connection with a mastectomy
7 shall include:
8 (1) reconstruction of the breast upon which the
9 mastectomy has been performed;
10 (2) surgery and reconstruction of the other breast
11 to produce a symmetrical appearance; and
12 (3) prostheses and treatment for physical
13 complications at all stages of mastectomy, including
14 lymphedemas.
15 Care shall be determined in consultation with the attending
16 physician and the patient. The offered coverage for
17 prosthetic devices and reconstructive surgery shall be
18 subject to the deductible and coinsurance conditions applied
19 to the mastectomy and all other terms and conditions
20 applicable to other benefits. When a mastectomy is performed
21 and there is no evidence of malignancy, then the offered
22 coverage may be limited to the provision of prosthetic
23 devices and reconstructive surgery to within 2 years after
24 the date of the mastectomy. As used in this Section,
25 "mastectomy" means the removal of all or part of the breast
26 for medically necessary reasons, as determined by a licensed
27 physician.
28 Written notice of the availability of coverage under this
29 Section shall be delivered to the enrollee upon enrollment
30 and annually thereafter. A health maintenance organization
31 may not deny to an enrollee eligibility, or continued
32 eligibility, to enroll or to renew coverage under the terms
33 of the plan solely for the purpose of avoiding the
34 requirements of this Section. A health maintenance
-5- LRB9113635JSpc
1 organization may not penalize or reduce or limit the
2 reimbursement of an attending provider or provide incentives
3 (monetary or otherwise) to an attending provider to induce
4 the provider to provide care to an insured in a manner
5 inconsistent with this Section.
6 (Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)
7 Section 99. Effective date. This Act takes effect upon
8 becoming law.