103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4421 Introduced , by Rep. Janet Yang Rohr SYNOPSIS AS INTRODUCED: 215 ILCS 5/356g from Ch. 73, par. 968g Amends the Illinois Insurance Code. In a provision concerning coverage for mammograms, provides that if a woman's physician has ordered the patient to receive breast tomosynthesis because it has been determined that high breast density will make low-dose mammography inaccurate or ineffective, the insurer shall not require the physician to order an additional low-dose mammography as a precondition to breast tomosynthesis, nor shall an insurer require the patient to receive a low-dose mammography as a precondition to breast tomosynthesis. Provides that if the results of a woman's first 2-dimensional mammogram screening determine that the patient has high breast density, coverage of breast tomosynthesis shall be provided at no cost to the insured, regardless of whether the breast tomosynthesis and 2-dimensional mammogram occurs within the same calendar year, coverage year, or 365-day period. LRB103 36181 RPS 66273 b STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4421 Introduced , by Rep. Janet Yang Rohr SYNOPSIS AS INTRODUCED: 215 ILCS 5/356g from Ch. 73, par. 968g 215 ILCS 5/356g from Ch. 73, par. 968g Amends the Illinois Insurance Code. In a provision concerning coverage for mammograms, provides that if a woman's physician has ordered the patient to receive breast tomosynthesis because it has been determined that high breast density will make low-dose mammography inaccurate or ineffective, the insurer shall not require the physician to order an additional low-dose mammography as a precondition to breast tomosynthesis, nor shall an insurer require the patient to receive a low-dose mammography as a precondition to breast tomosynthesis. Provides that if the results of a woman's first 2-dimensional mammogram screening determine that the patient has high breast density, coverage of breast tomosynthesis shall be provided at no cost to the insured, regardless of whether the breast tomosynthesis and 2-dimensional mammogram occurs within the same calendar year, coverage year, or 365-day period. LRB103 36181 RPS 66273 b LRB103 36181 RPS 66273 b STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4421 Introduced , by Rep. Janet Yang Rohr SYNOPSIS AS INTRODUCED:
215 ILCS 5/356g from Ch. 73, par. 968g 215 ILCS 5/356g from Ch. 73, par. 968g
215 ILCS 5/356g from Ch. 73, par. 968g
Amends the Illinois Insurance Code. In a provision concerning coverage for mammograms, provides that if a woman's physician has ordered the patient to receive breast tomosynthesis because it has been determined that high breast density will make low-dose mammography inaccurate or ineffective, the insurer shall not require the physician to order an additional low-dose mammography as a precondition to breast tomosynthesis, nor shall an insurer require the patient to receive a low-dose mammography as a precondition to breast tomosynthesis. Provides that if the results of a woman's first 2-dimensional mammogram screening determine that the patient has high breast density, coverage of breast tomosynthesis shall be provided at no cost to the insured, regardless of whether the breast tomosynthesis and 2-dimensional mammogram occurs within the same calendar year, coverage year, or 365-day period.
LRB103 36181 RPS 66273 b LRB103 36181 RPS 66273 b
LRB103 36181 RPS 66273 b
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
A BILL FOR
HB4421LRB103 36181 RPS 66273 b HB4421 LRB103 36181 RPS 66273 b
HB4421 LRB103 36181 RPS 66273 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 changing Section 356g as follows:
6 (215 ILCS 5/356g) (from Ch. 73, par. 968g)
7 Sec. 356g. Mammograms; mastectomies.
8 (a) Every insurer shall provide in each group or
9 individual policy, contract, or certificate of insurance
10 issued or renewed for persons who are residents of this State,
11 coverage for screening by low-dose mammography for all women
12 35 years of age or older for the presence of occult breast
13 cancer within the provisions of the policy, contract, or
14 certificate. The coverage shall be as follows:
15 (1) A baseline mammogram for women 35 to 39 years of
16 age.
17 (2) An annual mammogram for women 40 years of age or
18 older.
19 (3) A mammogram at the age and intervals considered
20 medically necessary by the woman's health care provider
21 for women under 40 years of age and having a family history
22 of breast cancer, prior personal history of breast cancer,
23 positive genetic testing, or other risk factors.
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4421 Introduced , by Rep. Janet Yang Rohr SYNOPSIS AS INTRODUCED:
215 ILCS 5/356g from Ch. 73, par. 968g 215 ILCS 5/356g from Ch. 73, par. 968g
215 ILCS 5/356g from Ch. 73, par. 968g
Amends the Illinois Insurance Code. In a provision concerning coverage for mammograms, provides that if a woman's physician has ordered the patient to receive breast tomosynthesis because it has been determined that high breast density will make low-dose mammography inaccurate or ineffective, the insurer shall not require the physician to order an additional low-dose mammography as a precondition to breast tomosynthesis, nor shall an insurer require the patient to receive a low-dose mammography as a precondition to breast tomosynthesis. Provides that if the results of a woman's first 2-dimensional mammogram screening determine that the patient has high breast density, coverage of breast tomosynthesis shall be provided at no cost to the insured, regardless of whether the breast tomosynthesis and 2-dimensional mammogram occurs within the same calendar year, coverage year, or 365-day period.
LRB103 36181 RPS 66273 b LRB103 36181 RPS 66273 b
LRB103 36181 RPS 66273 b
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
A BILL FOR
215 ILCS 5/356g from Ch. 73, par. 968g
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STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
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1 (4) For an individual or group policy of accident and
2 health insurance or a managed care plan that is amended,
3 delivered, issued, or renewed on or after the effective
4 date of this amendatory Act of the 101st General Assembly,
5 a comprehensive ultrasound screening and MRI of an entire
6 breast or breasts if a mammogram demonstrates
7 heterogeneous or dense breast tissue or when medically
8 necessary as determined by a physician licensed to
9 practice medicine in all of its branches.
10 (5) A screening MRI when medically necessary, as
11 determined by a physician licensed to practice medicine in
12 all of its branches.
13 (6) For an individual or group policy of accident and
14 health insurance or a managed care plan that is amended,
15 delivered, issued, or renewed on or after the effective
16 date of this amendatory Act of the 101st General Assembly,
17 a diagnostic mammogram when medically necessary, as
18 determined by a physician licensed to practice medicine in
19 all its branches, advanced practice registered nurse, or
20 physician assistant.
21 If a woman's physician has ordered the patient to receive
22 breast tomosynthesis because it has been determined that high
23 breast density will make low-dose mammography inaccurate or
24 ineffective, the insurer shall not require the physician to
25 order an additional low-dose mammography as a precondition to
26 breast tomosynthesis, nor shall an insurer require the patient
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1 to receive a low-dose mammography as a precondition to breast
2 tomosynthesis. This paragraph applies to an individual or
3 group policy of accident and health insurance or a managed
4 care plan that is amended, delivered, issued, or renewed on or
5 after the effective date of this amendatory Act of the 103rd
6 General Assembly.
7 If the results of a woman's first 2-dimensional mammogram
8 screening determine that the patient has high breast density,
9 coverage of breast tomosynthesis shall be provided at no cost
10 to the insured, regardless of whether the breast tomosynthesis
11 and 2-dimensional mammogram occurs within the same calendar
12 year, coverage year, or 365-day period. This paragraph applies
13 to an individual or group policy of accident and health
14 insurance or a managed care plan that is amended, delivered,
15 issued, or renewed on or after the effective date of this
16 amendatory Act of the 103rd General Assembly.
17 A policy subject to this subsection shall not impose a
18 deductible, coinsurance, copayment, or any other cost-sharing
19 requirement on the coverage provided; except that this
20 sentence does not apply to coverage of diagnostic mammograms
21 to the extent such coverage would disqualify a high-deductible
22 health plan from eligibility for a health savings account
23 pursuant to Section 223 of the Internal Revenue Code (26
24 U.S.C. 223).
25 For purposes of this Section:
26 "Diagnostic mammogram" means a mammogram obtained using
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1 diagnostic mammography.
2 "Diagnostic mammography" means a method of screening that
3 is designed to evaluate an abnormality in a breast, including
4 an abnormality seen or suspected on a screening mammogram or a
5 subjective or objective abnormality otherwise detected in the
6 breast.
7 "Low-dose mammography" means the x-ray examination of the
8 breast using equipment dedicated specifically for mammography,
9 including the x-ray tube, filter, compression device, and
10 image receptor, with radiation exposure delivery of less than
11 1 rad per breast for 2 views of an average size breast. The
12 term also includes digital mammography and includes breast
13 tomosynthesis. As used in this Section, the term "breast
14 tomosynthesis" means a radiologic procedure that involves the
15 acquisition of projection images over the stationary breast to
16 produce cross-sectional digital three-dimensional images of
17 the breast.
18 If, at any time, the Secretary of the United States
19 Department of Health and Human Services, or its successor
20 agency, promulgates rules or regulations to be published in
21 the Federal Register or publishes a comment in the Federal
22 Register or issues an opinion, guidance, or other action that
23 would require the State, pursuant to any provision of the
24 Patient Protection and Affordable Care Act (Public Law
25 111-148), including, but not limited to, 42 U.S.C.
26 18031(d)(3)(B) or any successor provision, to defray the cost
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1 of any coverage for breast tomosynthesis outlined in this
2 subsection, then the requirement that an insurer cover breast
3 tomosynthesis is inoperative other than any such coverage
4 authorized under Section 1902 of the Social Security Act, 42
5 U.S.C. 1396a, and the State shall not assume any obligation
6 for the cost of coverage for breast tomosynthesis set forth in
7 this subsection.
8 (a-5) Coverage as described by subsection (a) shall be
9 provided at no cost to the insured and shall not be applied to
10 an annual or lifetime maximum benefit.
11 (a-10) When health care services are available through
12 contracted providers and a person does not comply with plan
13 provisions specific to the use of contracted providers, the
14 requirements of subsection (a-5) are not applicable. When a
15 person does not comply with plan provisions specific to the
16 use of contracted providers, plan provisions specific to the
17 use of non-contracted providers must be applied without
18 distinction for coverage required by this Section and shall be
19 at least as favorable as for other radiological examinations
20 covered by the policy or contract.
21 (b) No policy of accident or health insurance that
22 provides for the surgical procedure known as a mastectomy
23 shall be issued, amended, delivered, or renewed in this State
24 unless that coverage also provides for prosthetic devices or
25 reconstructive surgery incident to the mastectomy. Coverage
26 for breast reconstruction in connection with a mastectomy
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1 shall include:
2 (1) reconstruction of the breast upon which the
3 mastectomy has been performed;
4 (2) surgery and reconstruction of the other breast to
5 produce a symmetrical appearance; and
6 (3) prostheses and treatment for physical
7 complications at all stages of mastectomy, including
8 lymphedemas.
9 Care shall be determined in consultation with the attending
10 physician and the patient. The offered coverage for prosthetic
11 devices and reconstructive surgery shall be subject to the
12 deductible and coinsurance conditions applied to the
13 mastectomy, and all other terms and conditions applicable to
14 other benefits. When a mastectomy is performed and there is no
15 evidence of malignancy then the offered coverage may be
16 limited to the provision of prosthetic devices and
17 reconstructive surgery to within 2 years after the date of the
18 mastectomy. As used in this Section, "mastectomy" means the
19 removal of all or part of the breast for medically necessary
20 reasons, as determined by a licensed physician.
21 Written notice of the availability of coverage under this
22 Section shall be delivered to the insured upon enrollment and
23 annually thereafter. An insurer may not deny to an insured
24 eligibility, or continued eligibility, to enroll or to renew
25 coverage under the terms of the plan solely for the purpose of
26 avoiding the requirements of this Section. An insurer may not
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