Bill Text: IL HB5001 | 2025-2026 | 104th General Assembly | Enrolled

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Bill Title: Reinserts the provisions of the engrossed bill with the following change. Provides that, notwithstanding any age requirement set forth in provisions concerning coverage for mammograms and mastectomies, coverage shall be consistent with evidence-based clinical guidelines and shall be provided in accordance with the determination of a health care provider (rather than in accordance with the determination of a health care provider, including coverage for individuals under 35 years of age when appropriate). Effective January 1, 2028.

Sponsorship: Partisan Bill (Democrat 40)

Status: (Passed) 2026-08-07 - Public Act . . . . . . . . . 104-0783 [HB5001 Detail]

Download: Illinois-2025-HB5001-Enrolled.html

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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
patients 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 patients 35 to 39 years
of age.
(2) An annual mammogram for patients 40 years of age
or older.
(3) A mammogram at the age and intervals considered
medically necessary by the patient's health care provider
for patients 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 January 1, 2020
(the effective date of Public Act 101-580) and before the
effective date of this amendatory Act of the 103rd 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.
(4.3) 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 103rd 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, advanced
practice registered nurse, or physician assistant.
(4.5) For a group policy of accident and health
insurance that is amended, delivered, issued, or renewed
on or after the effective date of this amendatory Act of
the 103rd General Assembly, molecular breast imaging (MBI)
of an entire breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue or when medically

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necessary as determined by a physician licensed to
practice medicine in all of its branches, advanced
practice registered nurse, or physician assistant.
(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 January 1, 2020
(the effective date of Public Act 101-580), 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.
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
diagnostic mammography.
"Diagnostic mammography" means a method of screening that

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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
of any coverage for breast tomosynthesis outlined in this
subsection, then the requirement that an insurer cover breast

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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.
(a-15) Notwithstanding any age requirement set forth in
this Section, coverage shall be consistent with evidence-based
clinical guidelines, including, but not limited to, guidelines
established by the National Comprehensive Cancer Network, and
shall be provided in accordance with the determination of a
health care provider. Nothing in this subsection shall be
construed to limit coverage otherwise required under this
Section based on age.

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(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
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.

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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
penalize or reduce or limit the reimbursement of an attending
provider or provide incentives (monetary or otherwise) to an
attending provider to induce the provider to provide care to
an insured in a manner inconsistent with this Section.
(c) Rulemaking authority to implement Public Act 95-1045,
if any, is conditioned on the rules being adopted in
accordance with all provisions of the Illinois Administrative
Procedure Act and all rules and procedures of the Joint
Committee on Administrative Rules; any purported rule not so
adopted, for whatever reason, is unauthorized.
(Source: P.A. 103-808, eff. 1-1-26.)
Section 99. Effective date. This Act takes effect January
1, 2028.