State of Illinois
92nd General Assembly
Legislation

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92_SB0866enr

 
SB866 Enrolled                                LRB9201220JSpcA

 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
 
SB866 Enrolled              -2-               LRB9201220JSpcA
 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
 
SB866 Enrolled              -3-               LRB9201220JSpcA
 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  that  provides  for  the
30    surgical procedure known as a  mastectomy  shall  be  issued,
31    amended,  delivered, or renewed in this State on or after the
32    effective date of this amendatory Act  of  the  92nd  General
 
SB866 Enrolled              -4-               LRB9201220JSpcA
 1    Assembly  unless  that  coverage also provides for prosthetic
 2    devices or reconstructive surgery incident to the mastectomy,
 3    providing  that  the  mastectomy  is  performed   after   the
 4    effective  date  of this amendatory Act.  Coverage for breast
 5    reconstruction in connection with a mastectomy shall include:
 6             (1)  reconstruction of the  breast  upon  which  the
 7        mastectomy has been performed;
 8             (2)  surgery  and reconstruction of the other breast
 9        to produce a symmetrical appearance; and
10             (3)  prostheses   and   treatment    for    physical
11        complications  at  all  stages  of  mastectomy, including
12        lymphedemas.
13    Care shall be determined in consultation with  the  attending
14    physician   and   the   patient.  The  offered  coverage  for
15    prosthetic  devices  and  reconstructive  surgery  shall   be
16    subject  to the deductible and coinsurance conditions applied
17    to  the  mastectomy  and  all  other  terms  and   conditions
18    applicable to other benefits.  When a mastectomy is performed
19    and  there  is  no  evidence  of malignancy, then the offered
20    coverage may  be  limited  to  the  provision  of  prosthetic
21    devices  and  reconstructive  surgery to within 2 years after
22    the  date  of  the  mastectomy.  As  used  in  this  Section,
23    "mastectomy" means the removal of all or part of  the  breast
24    for  medically necessary reasons, as determined by a licensed
25    physician.
26        Written notice of the availability of coverage under this
27    Section shall be delivered to the  enrollee  upon  enrollment
28    and  annually  thereafter.  A health maintenance organization
29    may  not  deny  to  an  enrollee  eligibility,  or  continued
30    eligibility, to enroll or to renew coverage under  the  terms
31    of   the   plan  solely  for  the  purpose  of  avoiding  the
32    requirements  of  this   Section.    A   health   maintenance
33    organization   may  not  penalize  or  reduce  or  limit  the
34    reimbursement of an attending provider or provide  incentives
 
SB866 Enrolled              -5-               LRB9201220JSpcA
 1    (monetary  or  otherwise)  to an attending provider to induce
 2    the provider to provide  care  to  an  insured  in  a  manner
 3    inconsistent with this Section.
 4    (Source: P.A. 90-7, eff. 6-10-97; 90-655, eff. 7-30-98.)

 5        Section  99.  Effective date.  This Act takes effect upon
 6    becoming law.

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