Public Act 095-0431
 		





SB1365 Enrolled
LRB095 04641 KBJ 24699 b






    AN ACT concerning insurance.

 
    Be it enacted by the People of the State of Illinois,
 
represented in the General Assembly:

 
    Section 5. The Illinois Insurance Code is amended  by 
changing Section 356g as follows:
 



    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)



    Sec. 356g. Mammograms; mastectomies. 

    (a) Every insurer shall provide in each group or individual

policy, contract, or certificate of insurance issued or renewed 
for persons
who are residents of this State, coverage for 
screening by low-dose
mammography for all women 35 years of age 
or older for the presence of
occult breast cancer within the 
provisions of the policy, contract, or
certificate. 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) A comprehensive ultrasound screening of an entire 
    breast or breasts if a mammogram demonstrates 
    heterogeneous or dense breast tissue, when medically 
    necessary as determined by a physician licensed to practice 
    medicine in all of its branches.

    These benefits shall be at least as favorable as for other 
radiological
examinations and subject to the same dollar 
limits, deductibles, and
co-insurance factors. For purposes of 
this Section, "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.

    (b) No policy of accident or health insurance that provides 
for
the surgical procedure known as a mastectomy shall be 
issued, amended,
delivered, or renewed in this State unless

that coverage also provides for prosthetic devices
or 
reconstructive surgery
incident to the mastectomy.
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 insured upon enrollment and 
annually thereafter.  An insurer
may not deny to an insured 
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.  An insurer 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.

(Source: P.A. 94-121, eff. 7-6-05.)

 
    Section 10. The Health Maintenance Organization Act is 
amended  by changing Section 4-6.1 as follows:
 



    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)



    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) A comprehensive ultrasound screening of an entire 
    breast or breasts if a mammogram demonstrates 
    heterogeneous or dense breast tissue, when medically 
    necessary as determined by a physician licensed to practice 
    medicine in all of its branches.

    These benefits shall be at least as favorable as for other 
radiological
examinations and subject to the same dollar 
limits, deductibles, and
co-insurance factors.  For purposes of 
this Section, "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.

    (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.

(Source: P.A. 94-121, eff. 7-6-05.)

 

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