HB5142 EngrossedLRB103 38742 RPS 68879 b HB5142 Engrossed LRB103 38742 RPS 68879 b
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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 Sections 356z.4a and 356z.40 as follows:
6 (215 ILCS 5/356z.4a)
7 Sec. 356z.4a. Coverage for abortion.
8 (a) Except as otherwise provided in this Section, no
9 individual or group policy of accident and health insurance
10 that provides pregnancy-related benefits may be issued,
11 amended, delivered, or renewed in this State after the
12 effective date of this amendatory Act of the 101st General
13 Assembly unless the policy provides a covered person with
14 coverage for abortion care. Regardless of whether the policy
15 otherwise provides prescription drug benefits, abortion care
16 coverage must include medications that are obtained through a
17 prescription and used to terminate a pregnancy, regardless of
18 whether there is proof of a pregnancy.
19 (b) Coverage for abortion care may not impose any
20 deductible, coinsurance, waiting period, or other cost-sharing
21 limitation that is greater than that required for other
22 pregnancy-related benefits covered by the policy. This
23 subsection does not apply to the extent that such coverage
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1 would disqualify a high-deductible health plan from
2 eligibility for a health savings account pursuant to Section
3 223 of the Internal Revenue Code.
4 (c) Except as otherwise authorized under this Section, a
5 policy shall not impose any restrictions or delays on the
6 coverage required under this Section.
7 (d) This Section does not, pursuant to 42 U.S.C.
8 18054(a)(6), apply to a multistate plan that does not provide
9 coverage for abortion.
10 (e) If the Department concludes that enforcement of this
11 Section may adversely affect the allocation of federal funds
12 to this State, the Department may grant an exemption to the
13 requirements, but only to the minimum extent necessary to
14 ensure the continued receipt of federal funds.
15 (Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)
16 (215 ILCS 5/356z.40)
17 Sec. 356z.40. Pregnancy and postpartum coverage.
18 (a) An individual or group policy of accident and health
19 insurance or managed care plan amended, delivered, issued, or
20 renewed on or after October 8, 2021 (the effective date of
21 Public Act 102-665) this amendatory Act of the 102nd General
22 Assembly shall provide coverage for pregnancy and newborn care
23 in accordance with 42 U.S.C. 18022(b) regarding essential
24 health benefits. For policies amended, delivered, issued, or
25 renewed on or after January 1, 2026, this subsection also
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1 applies to coverage for postpartum care.
2 (b) Benefits under this Section shall be as follows:
3 (1) An individual who has been identified as
4 experiencing a high-risk pregnancy by the individual's
5 treating provider shall have access to clinically
6 appropriate case management programs. As used in this
7 subsection, "case management" means a mechanism to
8 coordinate and assure continuity of services, including,
9 but not limited to, health services, social services, and
10 educational services necessary for the individual. "Case
11 management" involves individualized assessment of needs,
12 planning of services, referral, monitoring, and advocacy
13 to assist an individual in gaining access to appropriate
14 services and closure when services are no longer required.
15 "Case management" is an active and collaborative process
16 involving a single qualified case manager, the individual,
17 the individual's family, the providers, and the community.
18 This includes close coordination and involvement with all
19 service providers in the management plan for that
20 individual or family, including assuring that the
21 individual receives the services. As used in this
22 subsection, "high-risk pregnancy" means a pregnancy in
23 which the pregnant or postpartum individual or baby is at
24 an increased risk for poor health or complications during
25 pregnancy or childbirth, including, but not limited to,
26 hypertension disorders, gestational diabetes, and
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1 hemorrhage.
2 (2) An individual shall have access to medically
3 necessary treatment of a mental, emotional, nervous, or
4 substance use disorder or condition consistent with the
5 requirements set forth in this Section and in Sections
6 370c and 370c.1 of this Code.
7 (3) The benefits provided for inpatient and outpatient
8 services for the treatment of a mental, emotional,
9 nervous, or substance use disorder or condition related to
10 pregnancy or postpartum complications shall be provided if
11 determined to be medically necessary, consistent with the
12 requirements of Sections 370c and 370c.1 of this Code. The
13 facility or provider shall notify the insurer of both the
14 admission and the initial treatment plan within 48 hours
15 after admission or initiation of treatment. Nothing in
16 this paragraph shall prevent an insurer from applying
17 concurrent and post-service utilization review of health
18 care services, including review of medical necessity, case
19 management, experimental and investigational treatments,
20 managed care provisions, and other terms and conditions of
21 the insurance policy.
22 (4) The benefits for the first 48 hours of initiation
23 of services for an inpatient admission, detoxification or
24 withdrawal management program, or partial hospitalization
25 admission for the treatment of a mental, emotional,
26 nervous, or substance use disorder or condition related to
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1 pregnancy or postpartum complications shall be provided
2 without post-service or concurrent review of medical
3 necessity, as the medical necessity for the first 48 hours
4 of such services shall be determined solely by the covered
5 pregnant or postpartum individual's provider. Nothing in
6 this paragraph shall prevent an insurer from applying
7 concurrent and post-service utilization review, including
8 the review of medical necessity, case management,
9 experimental and investigational treatments, managed care
10 provisions, and other terms and conditions of the
11 insurance policy, of any inpatient admission,
12 detoxification or withdrawal management program admission,
13 or partial hospitalization admission services for the
14 treatment of a mental, emotional, nervous, or substance
15 use disorder or condition related to pregnancy or
16 postpartum complications received 48 hours after the
17 initiation of such services. If an insurer determines that
18 the services are no longer medically necessary, then the
19 covered person shall have the right to external review
20 pursuant to the requirements of the Health Carrier
21 External Review Act.
22 (5) If an insurer determines that continued inpatient
23 care, detoxification or withdrawal management, partial
24 hospitalization, intensive outpatient treatment, or
25 outpatient treatment in a facility is no longer medically
26 necessary, the insurer shall, within 24 hours, provide
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1 written notice to the covered pregnant or postpartum
2 individual and the covered pregnant or postpartum
3 individual's provider of its decision and the right to
4 file an expedited internal appeal of the determination.
5 The insurer shall review and make a determination with
6 respect to the internal appeal within 24 hours and
7 communicate such determination to the covered pregnant or
8 postpartum individual and the covered pregnant or
9 postpartum individual's provider. If the determination is
10 to uphold the denial, the covered pregnant or postpartum
11 individual and the covered pregnant or postpartum
12 individual's provider have the right to file an expedited
13 external appeal. An independent utilization review
14 organization shall make a determination within 72 hours.
15 If the insurer's determination is upheld and it is
16 determined that continued inpatient care, detoxification
17 or withdrawal management, partial hospitalization,
18 intensive outpatient treatment, or outpatient treatment is
19 not medically necessary, the insurer shall remain
20 responsible for providing benefits for the inpatient care,
21 detoxification or withdrawal management, partial
22 hospitalization, intensive outpatient treatment, or
23 outpatient treatment through the day following the date
24 the determination is made, and the covered pregnant or
25 postpartum individual shall only be responsible for any
26 applicable copayment, deductible, and coinsurance for the
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1 stay through that date as applicable under the policy. The
2 covered pregnant or postpartum individual shall not be
3 discharged or released from the inpatient facility,
4 detoxification or withdrawal management, partial
5 hospitalization, intensive outpatient treatment, or
6 outpatient treatment until all internal appeals and
7 independent utilization review organization appeals are
8 exhausted. A decision to reverse an adverse determination
9 shall comply with the Health Carrier External Review Act.
10 (6) Except as otherwise stated in this subsection (b)
11 and subsection (c), the benefits and cost-sharing shall be
12 provided to the same extent as for any other medical
13 condition covered under the policy.
14 (7) The benefits required by paragraphs (2) and (6) of
15 this subsection (b) are to be provided to all covered
16 pregnant or postpartum individuals with a diagnosis of a
17 mental, emotional, nervous, or substance use disorder or
18 condition. The presence of additional related or unrelated
19 diagnoses shall not be a basis to reduce or deny the
20 benefits required by this subsection (b).
21 (8) Insurers shall cover all services for pregnancy,
22 postpartum, and newborn care that are rendered by
23 perinatal doulas or licensed certified professional
24 midwives, including home births, home visits, and support
25 during labor, abortion, or miscarriage. Coverage shall
26 include the necessary equipment and medical supplies for a
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1 home birth. For home visits by a perinatal doula, not
2 counting any home birth, the policy may limit coverage to
3 16 visits before and 16 visits after a birth, miscarriage,
4 or abortion, provided that the policy shall not be
5 required to cover more than $8,000 for doula visits for
6 each pregnancy and subsequent postpartum period. As used
7 in this paragraph (8), "perinatal doula" has the meaning
8 given in subsection (a) of Section 5-18.5 of the Illinois
9 Public Aid Code.
10 (9) Coverage for pregnancy, postpartum, and newborn
11 care shall include home visits by lactation consultants
12 and the purchase of breast pumps and breast pump supplies,
13 including such breast pumps, breast pump supplies,
14 breastfeeding supplies, and feeding aids as recommended by
15 the lactation consultant. As used in this paragraph (9),
16 "lactation consultant" means an International
17 Board-Certified Lactation Consultant, a certified
18 lactation specialist with a certification from Lactation
19 Education Consultants, or a certified lactation counselor
20 as defined in subsection (a) of Section 5-18.10 of the
21 Illinois Public Aid Code.
22 (10) Coverage for postpartum services shall apply for
23 all covered services rendered within the first 12 months
24 after the end of pregnancy, subject to any policy
25 limitation on home visits by a perinatal doula allowed
26 under paragraph (8) of this subsection (b). Nothing in
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1 this paragraph (10) shall be construed to require a policy
2 to cover services for an individual who is no longer
3 insured or enrolled under the policy. If an individual
4 becomes insured or enrolled under a new policy, the new
5 policy shall cover the individual consistent with the time
6 period and limitations allowed under this paragraph (10).
7 This paragraph (10) is subject to the requirements of
8 Section 25 of the Managed Care Reform and Patient Rights
9 Act, Section 20 of the Network Adequacy and Transparency
10 Act, and 42 U.S.C. 300gg-113.
11 (c) All coverage described in subsection (b), other than
12 health care services for home births, shall be provided
13 without cost-sharing, except that, for mental health services,
14 the cost-sharing prohibition does not apply to inpatient or
15 residential services, and, for substance use disorder
16 services, the cost-sharing prohibition applies only to levels
17 of treatment below and not including Level 3.1 (Clinically
18 Managed Low-Intensity Residential), as established by the
19 American Society for Addiction Medicine. This subsection does
20 not apply to the extent such coverage would disqualify a
21 high-deductible health plan from eligibility for a health
22 savings account pursuant to Section 223 of the Internal
23 Revenue Code.
24 (Source: P.A. 102-665, eff. 10-8-21.)
25 Section 10. The Illinois Public Aid Code is amended by
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1 changing Sections 5-16.7 and 5-18.5 as follows:
2 (305 ILCS 5/5-16.7)
3 Sec. 5-16.7. Post-parturition care. The medical assistance
4 program shall provide the post-parturition care benefits
5 required to be covered by a policy of accident and health
6 insurance under Section 356s of the Illinois Insurance Code.
7 On and after July 1, 2012, the Department shall reduce any
8 rate of reimbursement for services or other payments or alter
9 any methodologies authorized by this Code to reduce any rate
10 of reimbursement for services or other payments in accordance
11 with Section 5-5e.
12 (Source: P.A. 97-689, eff. 6-14-12.)
13 (305 ILCS 5/5-18.5)
14 Sec. 5-18.5. Perinatal doula and evidence-based home
15 visiting services.
16 (a) As used in this Section:
17 "Home visiting" means a voluntary, evidence-based strategy
18 used to support pregnant people, infants, and young children
19 and their caregivers to promote infant, child, and maternal
20 health, to foster educational development and school
21 readiness, and to help prevent child abuse and neglect. Home
22 visitors are trained professionals whose visits and activities
23 focus on promoting strong parent-child attachment to foster
24 healthy child development.
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1 "Perinatal doula" means a trained provider who provides
2 regular, voluntary physical, emotional, and educational
3 support, but not medical or midwife care, to pregnant and
4 birthing persons before, during, and after childbirth,
5 otherwise known as the perinatal period.
6 "Perinatal doula training" means any doula training that
7 focuses on providing support throughout the prenatal, labor
8 and delivery, or postpartum period, and reflects the type of
9 doula care that the doula seeks to provide.
10 (b) Notwithstanding any other provision of this Article,
11 perinatal doula services and evidence-based home visiting
12 services shall be covered under the medical assistance
13 program, subject to appropriation, for persons who are
14 otherwise eligible for medical assistance under this Article.
15 Perinatal doula services include regular visits beginning in
16 the prenatal period and continuing into the postnatal period,
17 inclusive of continuous support during labor and delivery,
18 that support healthy pregnancies and positive birth outcomes.
19 Perinatal doula services may be embedded in an existing
20 program, such as evidence-based home visiting. Perinatal doula
21 services provided during the prenatal period may be provided
22 weekly, services provided during the labor and delivery period
23 may be provided for the entire duration of labor and the time
24 immediately following birth, and services provided during the
25 postpartum period may be provided up to 12 months postpartum.
26 (b-5) Notwithstanding any other provision of this Article,
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1 beginning January 1, 2025 2023, licensed certified
2 professional midwife services shall be covered under the
3 medical assistance program, subject to appropriation, for
4 persons who are otherwise eligible for medical assistance
5 under this Article. The Department shall consult with midwives
6 on reimbursement rates for midwifery services.
7 (c) The Department of Healthcare and Family Services shall
8 adopt rules to administer this Section. In this rulemaking,
9 the Department shall consider the expertise of and consult
10 with doula program experts, doula training providers,
11 practicing doulas, and home visiting experts, along with State
12 agencies implementing perinatal doula services and relevant
13 bodies under the Illinois Early Learning Council. This body of
14 experts shall inform the Department on the credentials
15 necessary for perinatal doula and home visiting services to be
16 eligible for Medicaid reimbursement and the rate of
17 reimbursement for home visiting and perinatal doula services
18 in the prenatal, labor and delivery, and postpartum periods.
19 Every 2 years, the Department shall assess the rates of
20 reimbursement for perinatal doula and home visiting services
21 and adjust rates accordingly.
22 (d) The Department shall seek such State plan amendments
23 or waivers as may be necessary to implement this Section and
24 shall secure federal financial participation for expenditures
25 made by the Department in accordance with this Section.
26 (Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
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