Bill Text: IL HB4421 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: 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.

Spectrum: Partisan Bill (Democrat 14-0)

Status: (Introduced) 2024-04-05 - Rule 19(a) / Re-referred to Rules Committee [HB4421 Detail]

Download: Illinois-2023-HB4421-Introduced.html

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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.
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STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT MAY APPLY
A BILL FOR
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AN ACT concerning regulation.
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.

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(4) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after the effective
date of this amendatory Act of the 101st General Assembly,
a comprehensive ultrasound screening and MRI of an entire
breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically
necessary as determined by a physician licensed to
practice medicine in all of its branches.
(5) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in
all of its branches.
(6) For an individual or group policy of accident and
health insurance or a managed care plan that is amended,
delivered, issued, or renewed on or after the effective
date of this amendatory Act of the 101st General Assembly,
a diagnostic mammogram when medically necessary, as
determined by a physician licensed to practice medicine in
all its branches, advanced practice registered nurse, or
physician assistant.
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

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to receive a low-dose mammography as a precondition to breast
tomosynthesis. This paragraph applies to an individual or
group policy of accident and health insurance or a managed
care plan that is amended, delivered, issued, or renewed on or
after the effective date of this amendatory Act of the 103rd
General Assembly.
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. This paragraph applies
to an individual or group policy of accident and health
insurance or a managed care plan that is amended, delivered,
issued, or renewed on or after the effective date of this
amendatory Act of the 103rd General Assembly.
A policy subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided; except that this
sentence does not apply to coverage of diagnostic mammograms
to the extent such coverage would disqualify a high-deductible
health plan from eligibility for a health savings account
pursuant to Section 223 of the Internal Revenue Code (26
U.S.C. 223).
For purposes of this Section:
"Diagnostic mammogram" means a mammogram obtained using

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diagnostic mammography.
"Diagnostic mammography" means a method of screening that
is designed to evaluate an abnormality in a breast, including
an abnormality seen or suspected on a screening mammogram or a
subjective or objective abnormality otherwise detected in the
breast.
"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. The
term also includes digital mammography and includes breast
tomosynthesis. As used in this Section, the term "breast
tomosynthesis" means a radiologic procedure that involves the
acquisition of projection images over the stationary breast to
produce cross-sectional digital three-dimensional images of
the breast.
If, at any time, the Secretary of the United States
Department of Health and Human Services, or its successor
agency, promulgates rules or regulations to be published in
the Federal Register or publishes a comment in the Federal
Register or issues an opinion, guidance, or other action that
would require the State, pursuant to any provision of the
Patient Protection and Affordable Care Act (Public Law
111-148), including, but not limited to, 42 U.S.C.
18031(d)(3)(B) or any successor provision, to defray the cost

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of any coverage for breast tomosynthesis outlined in this
subsection, then the requirement that an insurer cover breast
tomosynthesis is inoperative other than any such coverage
authorized under Section 1902 of the Social Security Act, 42
U.S.C. 1396a, and the State shall not assume any obligation
for the cost of coverage for breast tomosynthesis set forth in
this subsection.
(a-5) Coverage as described by subsection (a) shall be
provided at no cost to the insured and shall not be applied to
an annual or lifetime maximum benefit.
(a-10) When health care services are available through
contracted providers and a person does not comply with plan
provisions specific to the use of contracted providers, the
requirements of subsection (a-5) are not applicable. When a
person does not comply with plan provisions specific to the
use of contracted providers, plan provisions specific to the
use of non-contracted providers must be applied without
distinction for coverage required by this Section and shall be
at least as favorable as for other radiological examinations
covered by the policy or contract.
(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

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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

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