HB5001 amends the Illinois Insurance Code’s mammography and mastectomy coverage requirements. The bill requires insurers to cover low-dose screening mammograms for patients age 35 and older, including a baseline mammogram for ages 35 to 39 and annual mammograms for those 40 and older. It also preserves coverage for medically necessary mammograms for younger patients with elevated risk factors such as family history, prior breast cancer, positive genetic testing, or other risk factors.
The bill expands and clarifies coverage for additional breast imaging and follow-up services. For qualifying health and managed care policies, it requires coverage of ultrasound screening, MRI, molecular breast imaging, and diagnostic mammograms when medically necessary, and it specifies that these services must generally be provided without deductible, coinsurance, copayment, or other cost-sharing, subject to an exception for high-deductible health plans where required to preserve HSA eligibility. It also adds a new provision stating that coverage must be consistent with evidence-based clinical guidelines, including National Comprehensive Cancer Network guidelines, and must be provided according to a health care provider’s determination, without limiting existing age-based coverage.
The bill also reinforces existing mastectomy-related protections. Policies covering mastectomy must also cover prosthetic devices and reconstructive surgery, including reconstruction of the affected breast, surgery on the other breast for symmetry, and treatment for complications such as lymphedema. The bill requires written notice of these benefits at enrollment and annually thereafter, prohibits insurers from denying or limiting coverage to avoid these requirements, and bars incentives or reimbursement penalties that would pressure providers to deviate from the statute.
HB5001’s impact on state law is to broaden and modernize mandated breast cancer screening and reconstruction benefits under Illinois insurance law, while also updating definitions and aligning coverage decisions more closely with current clinical guidelines and provider judgment. It applies to individual and group accident and health insurance policies and managed care plans, and it includes effective-date language that phases in the changes for policies issued or renewed on or after January 1, 2028.
There is no recorded committee transcript or vote history in the provided materials, so the overall sentiment cannot be measured from debate or roll call data. Based on the bill text alone, the measure appears consumer- and patient-protective, with a focus on expanding access to breast cancer screening and treatment-related coverage. The main potential point of contention is the insurance mandate itself, especially the cost-sharing restrictions and the added obligations on insurers, though the bill includes exceptions intended to preserve high-deductible health plan/HSA compatibility and to tie coverage to medical necessity and evidence-based guidelines.
HB5001 amends Section 356g of the Illinois Insurance Code (215 ILCS 5/356g) to expand mandated breast cancer screening, diagnostic imaging, and mastectomy-related coverage for applicable accident and health insurance policies and managed care plans. It adds or clarifies requirements for low-dose mammography, ultrasound, MRI, molecular breast imaging, diagnostic mammograms, and reconstructive/prosthetic benefits, while restricting cost-sharing for covered services and requiring notice to insureds. The bill also incorporates evidence-based clinical guideline language and sets an effective date of January 1, 2028.
No committee discussion or vote record was provided, so there is no direct evidence of support or opposition from legislative debate. The bill’s structure and subject matter suggest a broadly favorable, health-care access-oriented policy approach, aimed at strengthening breast cancer screening and reconstruction coverage for insured residents. Any opposition would likely center on insurer mandate costs and administrative requirements rather than the underlying health policy goals.
The most likely areas of contention are the expanded insurance mandates, the prohibition on deductibles and other cost-sharing for covered services, and the requirement that insurers cover advanced imaging such as MRI, ultrasound, and molecular breast imaging when medically necessary. Insurers may also focus on the potential cost implications of the new age-based screening requirements and the requirement to follow evidence-based clinical guidelines. The bill partially addresses these concerns by preserving high-deductible health plan/HSA rules and by tying some coverage decisions to provider judgment and medical necessity.