INS-MAMMOGRAM COVERAGE

Illinois General Assembly - Full Text of HB5001

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Full Text of HB5001

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HB5001 - 104th General Assembly

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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
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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
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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
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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.

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