Women have special health care needs.  The State of Illinois has passed the following laws related specifically to female health care issues and insurance requirements. 

NOTE:  The following laws do not apply to self-insured employers or to trusts or insurance policies written outside Illinois.  However, for HMOs, the laws do apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois.  To determine if your HMO provides the benefits required by the following laws, you should contact the HMO directly or check your certificate of coverage.

Birth Control 

Effective January 1, 2004 all individual and group health insurance and HMO policies that provide coverage for outpatient services and outpatient prescription drugs or devices, must also provide coverage for all outpatient contraceptive services and all outpatient contraceptive drugs and devices approved by the Food and Drug Administration.  Deductibles, coinsurance, waiting periods are the same as those imposed for any other outpatient prescription drug or device under the policy.

 

                                                                  

Breast Surgery

 

Mastectomy – Breast Reconstruction – All group and individual health insurance and HMO policies that provide coverage for mastectomies must also cover prosthetic devices or reconstructive surgery related to the mastectomy.  Prosthetic devices include breast prosthesis and bras.  Reconstructive surgery includes reconstruction of the breast on which the mastectomy has been performed, as well as surgery and reconstruction of the other breast to produce symmetrical appearance.  Coverage is also required for prosthetic devices and treatment for physical complications at all stages of mastectomy, including lymph edemas.  The coverage may be subject to annual deductibles and coinsurance provisions as deemed appropriate and consistent with other benefits covered under the insurance. (215 ILCS 5/356g(b) and 215 ILCS 125/4-6.1))

Post mastectomy hospital stay – All group and individual health insurance and HMO policies must allow the attending physician to determine the length of hospital stay following a mastectomy, the removal of a breast.  The insurance company or HMO must provide coverage as long as the attending physician determines the length of stay to be medically necessary and in accordance with protocols and guidelines based on sound scientific evidence and an evaluation of the patient. (215 ILCS 5/356t and 215 ILCS 125/4-6.5)

Breast Implants - In Illinois, no individual or group health insurance or HMO policy may deny coverage for the removal of breast implants if:

• the implants were not inserted for purely cosmetic reasons; and
• it is medically necessary for the breast implants to be removed.

Implants inserted after a mastectomy due to sickness or injury are not considered purely cosmetic.

 

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