HB 5001

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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,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by
5changing 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
9individual policy, contract, or certificate of insurance
10issued or renewed for persons who are residents of this State,
11coverage for screening by low-dose mammography for all
12patients 35 years of age or older for the presence of occult
13breast cancer within the provisions of the policy, contract,
14or 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
16deductible, coinsurance, copayment, or any other cost-sharing
17requirement on the coverage provided; except that this
18sentence does not apply to coverage of diagnostic mammograms
19to the extent such coverage would disqualify a high-deductible
20health plan from eligibility for a health savings account
21pursuant to Section 223 of the Internal Revenue Code (26
22U.S.C. 223).
23    For purposes of this Section:
24    "Diagnostic mammogram" means a mammogram obtained using
25diagnostic mammography.
26    "Diagnostic mammography" means a method of screening that
		HB5001 Enrolled	- 4 -	LRB104 15320 BAB 28474 b
1is designed to evaluate an abnormality in a breast, including
2an abnormality seen or suspected on a screening mammogram or a
3subjective or objective abnormality otherwise detected in the
4breast.
5    "Low-dose mammography" means the x-ray examination of the
6breast using equipment dedicated specifically for mammography,
7including the x-ray tube, filter, compression device, and
8image receptor, with radiation exposure delivery of less than
91 rad per breast for 2 views of an average size breast. The
10term also includes digital mammography and includes breast
11tomosynthesis. As used in this Section, the term "breast
12tomosynthesis" means a radiologic procedure that involves the
13acquisition of projection images over the stationary breast to
14produce cross-sectional digital three-dimensional images of
15the breast.
16    If, at any time, the Secretary of the United States
17Department of Health and Human Services, or its successor
18agency, promulgates rules or regulations to be published in
19the Federal Register or publishes a comment in the Federal
20Register or issues an opinion, guidance, or other action that
21would require the State, pursuant to any provision of the
22Patient Protection and Affordable Care Act (Public Law
23111-148), including, but not limited to, 42 U.S.C.
2418031(d)(3)(B) or any successor provision, to defray the cost
25of any coverage for breast tomosynthesis outlined in this
26subsection, then the requirement that an insurer cover breast
		HB5001 Enrolled	- 5 -	LRB104 15320 BAB 28474 b
1tomosynthesis is inoperative other than any such coverage
2authorized under Section 1902 of the Social Security Act, 42
3U.S.C. 1396a, and the State shall not assume any obligation
4for the cost of coverage for breast tomosynthesis set forth in
5this subsection.
6    (a-5) Coverage as described by subsection (a) shall be
7provided at no cost to the insured and shall not be applied to
8an annual or lifetime maximum benefit.
9    (a-10) When health care services are available through
10contracted providers and a person does not comply with plan
11provisions specific to the use of contracted providers, the
12requirements of subsection (a-5) are not applicable. When a
13person does not comply with plan provisions specific to the
14use of contracted providers, plan provisions specific to the
15use of non-contracted providers must be applied without
16distinction for coverage required by this Section and shall be
17at least as favorable as for other radiological examinations
18covered by the policy or contract.
19    (a-15) Notwithstanding any age requirement set forth in 
20this Section, coverage shall be consistent with evidence-based 
21clinical guidelines, including, but not limited to, guidelines 
22established by the National Comprehensive Cancer Network, and 
23shall be provided in accordance with the determination of a 
24health care provider. Nothing in this subsection shall be 
25construed to limit coverage otherwise required under this 
26Section based on age.
		HB5001 Enrolled	- 6 -	LRB104 15320 BAB 28474 b
1    (b) No policy of accident or health insurance that
2provides for the surgical procedure known as a mastectomy
3shall be issued, amended, delivered, or renewed in this State
4unless that coverage also provides for prosthetic devices or
5reconstructive surgery incident to the mastectomy. Coverage
6for breast reconstruction in connection with a mastectomy
7shall 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.
15Care shall be determined in consultation with the attending
16physician and the patient. The offered coverage for prosthetic
17devices and reconstructive surgery shall be subject to the
18deductible and coinsurance conditions applied to the
19mastectomy, and all other terms and conditions applicable to
20other benefits. When a mastectomy is performed and there is no
21evidence of malignancy then the offered coverage may be
22limited to the provision of prosthetic devices and
23reconstructive surgery to within 2 years after the date of the
24mastectomy. As used in this Section, "mastectomy" means the
25removal of all or part of the breast for medically necessary
26reasons, as determined by a licensed physician.
		HB5001 Enrolled	- 7 -	LRB104 15320 BAB 28474 b
1    Written notice of the availability of coverage under this
2Section shall be delivered to the insured upon enrollment and
3annually thereafter. An insurer may not deny to an insured
4eligibility, or continued eligibility, to enroll or to renew
5coverage under the terms of the plan solely for the purpose of
6avoiding the requirements of this Section. An insurer may not
7penalize or reduce or limit the reimbursement of an attending
8provider or provide incentives (monetary or otherwise) to an
9attending provider to induce the provider to provide care to
10an insured in a manner inconsistent with this Section.
11    (c) Rulemaking authority to implement Public Act 95-1045,
12if any, is conditioned on the rules being adopted in
13accordance with all provisions of the Illinois Administrative
14Procedure Act and all rules and procedures of the Joint
15Committee on Administrative Rules; any purported rule not so
16adopted, 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
191, 2028.