HB5001: INS-MAMMOGRAM COVERAGE

HB5001 Enrolled LRB104 15320 BAB 28474 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 12 patients 35 years of age or older for the presence of occult 13 breast cancer within the provisions of the policy, contract, 14 or certificate. The coverage shall be as follows: 15 (1) A baseline mammogram for patients 35 to 39 years 16 of age. 17 (2) An annual mammogram for patients 40 years of age 18 or older. 19 (3) A mammogram at the age and intervals considered 20 medically necessary by the patient's health care provider 21 for patients under 40 years of age and having a family 22 history of breast cancer, prior personal history of breast 23 cancer, positive genetic testing, or other risk factors. HB5001 Enrolled - 2 - LRB104 15320 BAB 28474 b 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 January 1, 2020 4 (the effective date of Public Act 101-580) and before the 5 effective date of this amendatory Act of the 103rd General 6 Assembly, a comprehensive ultrasound screening and MRI of 7 an entire breast or breasts if a mammogram demonstrates 8 heterogeneous or dense breast tissue or when medically 9 necessary as determined by a physician licensed to 10 practice medicine in all of its branches. 11 (4.3) For an individual or group policy of accident 12 and health insurance or a managed care plan that is 13 amended, delivered, issued, or renewed on or after the 14 effective date of this amendatory Act of the 103rd General 15 Assembly, a comprehensive ultrasound screening and MRI of 16 an entire breast or breasts if a mammogram demonstrates 17 heterogeneous or dense breast tissue or when medically 18 necessary as determined by a physician licensed to 19 practice medicine in all of its branches, advanced 20 practice registered nurse, or physician assistant. 21 (4.5) For a group policy of accident and health 22 insurance that is amended, delivered, issued, or renewed 23 on or after the effective date of this amendatory Act of 24 the 103rd General Assembly, molecular breast imaging (MBI) 25 of an entire breast or breasts if a mammogram demonstrates 26 heterogeneous or dense breast tissue or when medically HB5001 Enrolled - 3 - LRB104 15320 BAB 28474 b 1 necessary as determined by a physician licensed to 2 practice medicine in all of its branches, advanced 3 practice registered nurse, or physician assistant. 4 (5) A screening MRI when medically necessary, as 5 determined by a physician licensed to practice medicine in 6 all of its branches. 7 (6) For an individual or group policy of accident and 8 health insurance or a managed care plan that is amended, 9 delivered, issued, or renewed on or after January 1, 2020 10 (the effective date of Public Act 101-580), a diagnostic 11 mammogram when medically necessary, as determined by a 12 physician licensed to practice medicine in all its 13 branches, advanced practice registered nurse, or physician 14 assistant. 15 A policy subject to this subsection shall not impose a 16 deductible, coinsurance, copayment, or any other cost-sharing 17 requirement on the coverage provided; except that this 18 sentence does not apply to coverage of diagnostic mammograms 19 to the extent such coverage would disqualify a high-deductible 20 health plan from eligibility for a health savings account 21 pursuant to Section 223 of the Internal Revenue Code (26 22 U.S.C. 223). 23 For purposes of this Section: 24 "Diagnostic mammogram" means a mammogram obtained using 25 diagnostic mammography. 26 "Diagnostic mammography" means a method of screening that HB5001 Enrolled - 4 - LRB104 15320 BAB 28474 b 1 is designed to evaluate an abnormality in a breast, including 2 an abnormality seen or suspected on a screening mammogram or a 3 subjective or objective abnormality otherwise detected in the 4 breast. 5 "Low-dose mammography" means the x-ray examination of the 6 breast using equipment dedicated specifically for mammography, 7 including the x-ray tube, filter, compression device, and 8 image receptor, with radiation exposure delivery of less than 9 1 rad per breast for 2 views of an average size breast. The 10 term also includes digital mammography and includes breast 11 tomosynthesis. As used in this Section, the term "breast 12 tomosynthesis" means a radiologic procedure that involves the 13 acquisition of projection images over the stationary breast to 14 produce cross-sectional digital three-dimensional images of 15 the breast. 16 If, at any time, the Secretary of the United States 17 Department of Health and Human Services, or its successor 18 agency, promulgates rules or regulations to be published in 19 the Federal Register or publishes a comment in the Federal 20 Register or issues an opinion, guidance, or other action that 21 would require the State, pursuant to any provision of the 22 Patient Protection and Affordable Care Act (Public Law 23 111-148), including, but not limited to, 42 U.S.C. 24 18031(d)(3)(B) or any successor provision, to defray the cost 25 of any coverage for breast tomosynthesis outlined in this 26 subsection, then the requirement that an insurer cover breast HB5001 Enrolled - 5 - LRB104 15320 BAB 28474 b 1 tomosynthesis is inoperative other than any such coverage 2 authorized under Section 1902 of the Social Security Act, 42 3 U.S.C. 1396a, and the State shall not assume any obligation 4 for the cost of coverage for breast tomosynthesis set forth in 5 this subsection. 6 (a-5) Coverage as described by subsection (a) shall be 7 provided at no cost to the insured and shall not be applied to 8 an annual or lifetime maximum benefit. 9 (a-10) When health care services are available through 10 contracted providers and a person does not comply with plan 11 provisions specific to the use of contracted providers, the 12 requirements of subsection (a-5) are not applicable. When a 13 person does not comply with plan provisions specific to the 14 use of contracted providers, plan provisions specific to the 15 use of non-contracted providers must be applied without 16 distinction for coverage required by this Section and shall be 17 at least as favorable as for other radiological examinations 18 covered by the policy or contract. 19 (a-15) Notwithstanding any age requirement set forth in 20 this Section, coverage shall be consistent with evidence-based 21 clinical guidelines, including, but not limited to, guidelines 22 established by the National Comprehensive Cancer Network, and 23 shall be provided in accordance with the determination of a 24 health care provider. Nothing in this subsection shall be 25 construed to limit coverage otherwise required under this 26 Section based on age. HB5001 Enrolled - 6 - LRB104 15320 BAB 28474 b 1 (b) No policy of accident or health insurance that 2 provides for the surgical procedure known as a mastectomy 3 shall be issued, amended, delivered, or renewed in this State 4 unless that coverage also provides for prosthetic devices or 5 reconstructive surgery incident to the mastectomy. 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 to 11 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 prosthetic 17 devices and reconstructive surgery shall be subject to the 18 deductible and coinsurance conditions applied to the 19 mastectomy, and all other terms and conditions applicable to 20 other benefits. When a mastectomy is performed and there is no 21 evidence of malignancy then the offered coverage may be 22 limited to the provision of prosthetic devices and 23 reconstructive surgery to within 2 years after the date of the 24 mastectomy. As used in this Section, "mastectomy" means the 25 removal of all or part of the breast for medically necessary 26 reasons, as determined by a licensed physician. HB5001 Enrolled - 7 - LRB104 15320 BAB 28474 b 1 Written notice of the availability of coverage under this 2 Section shall be delivered to the insured upon enrollment and 3 annually thereafter. An insurer may not deny to an insured 4 eligibility, or continued eligibility, to enroll or to renew 5 coverage under the terms of the plan solely for the purpose of 6 avoiding the requirements of this Section. An insurer may not 7 penalize or reduce or limit the reimbursement of an attending 8 provider or provide incentives (monetary or otherwise) to an 9 attending provider to induce the provider to provide care to 10 an insured in a manner inconsistent with this Section. 11 (c) Rulemaking authority to implement Public Act 95-1045, 12 if any, is conditioned on the rules being adopted in 13 accordance with all provisions of the Illinois Administrative 14 Procedure Act and all rules and procedures of the Joint 15 Committee on Administrative Rules; any purported rule not so 16 adopted, for whatever reason, is unauthorized. 17 (Source: P.A. 103-808, eff. 1-1-26 .) 18 Section 99. Effective date. This Act takes effect January 19 1, 2028.