Illinois 2023-2024 Regular Session

Illinois House Bill HB5142 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Public Act 103-0720
2	1		HB5142 EnrolledLRB103 38742 RPS 68879 b HB5142 Enrolled LRB103 38742 RPS 68879 b
3	2		HB5142 Enrolled LRB103 38742 RPS 68879 b
4		-	AN ACT concerning regulation.
5		-	Be it enacted by the People of the State of Illinois,
6		-	represented in the General Assembly:
7		-	Section 5. The Illinois Insurance Code is amended by
8		-	changing Sections 356z.4a and 356z.40 as follows:
9		-	(215 ILCS 5/356z.4a)
10		-	Sec. 356z.4a. Coverage for abortion.
11		-	(a) Except as otherwise provided in this Section, no
12		-	individual or group policy of accident and health insurance
13		-	that provides pregnancy-related benefits may be issued,
14		-	amended, delivered, or renewed in this State after the
15		-	effective date of this amendatory Act of the 101st General
16		-	Assembly unless the policy provides a covered person with
17		-	coverage for abortion care. Regardless of whether the policy
18		-	otherwise provides prescription drug benefits, abortion care
19		-	coverage must include medications that are obtained through a
20		-	prescription and used to terminate a pregnancy, regardless of
21		-	whether there is proof of a pregnancy.
22		-	(b) Coverage for abortion care may not impose any
23		-	deductible, coinsurance, waiting period, or other cost-sharing
24		-	limitation that is greater than that required for other
25		-	pregnancy-related benefits covered by the policy. This
26		-	subsection does not apply to the extent that such coverage
	3	+	1 AN ACT concerning regulation.
	4	+	2 Be it enacted by the People of the State of Illinois,
	5	+	3 represented in the General Assembly:
	6	+	4 Section 5. The Illinois Insurance Code is amended by
	7	+	5 changing Sections 356z.4a and 356z.40 as follows:
	8	+	6 (215 ILCS 5/356z.4a)
	9	+	7 Sec. 356z.4a. Coverage for abortion.
	10	+	8 (a) Except as otherwise provided in this Section, no
	11	+	9 individual or group policy of accident and health insurance
	12	+	10 that provides pregnancy-related benefits may be issued,
	13	+	11 amended, delivered, or renewed in this State after the
	14	+	12 effective date of this amendatory Act of the 101st General
	15	+	13 Assembly unless the policy provides a covered person with
	16	+	14 coverage for abortion care. Regardless of whether the policy
	17	+	15 otherwise provides prescription drug benefits, abortion care
	18	+	16 coverage must include medications that are obtained through a
	19	+	17 prescription and used to terminate a pregnancy, regardless of
	20	+	18 whether there is proof of a pregnancy.
	21	+	19 (b) Coverage for abortion care may not impose any
	22	+	20 deductible, coinsurance, waiting period, or other cost-sharing
	23	+	21 limitation that is greater than that required for other
	24	+	22 pregnancy-related benefits covered by the policy. This
	25	+	23 subsection does not apply to the extent that such coverage
27	26
28	27
29	28
30	29		HB5142 Enrolled LRB103 38742 RPS 68879 b
31	30
32	31
33		-	would disqualify a high-deductible health plan from
34		-	eligibility for a health savings account pursuant to Section
35		-	223 of the Internal Revenue Code.
36		-	(c) Except as otherwise authorized under this Section, a
37		-	policy shall not impose any restrictions or delays on the
38		-	coverage required under this Section.
39		-	(d) This Section does not, pursuant to 42 U.S.C.
40		-	18054(a)(6), apply to a multistate plan that does not provide
41		-	coverage for abortion.
42		-	(e) If the Department concludes that enforcement of this
43		-	Section may adversely affect the allocation of federal funds
44		-	to this State, the Department may grant an exemption to the
45		-	requirements, but only to the minimum extent necessary to
46		-	ensure the continued receipt of federal funds.
47		-	(Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)
48		-	(215 ILCS 5/356z.40)
49		-	Sec. 356z.40. Pregnancy and postpartum coverage.
50		-	(a) An individual or group policy of accident and health
51		-	insurance or managed care plan amended, delivered, issued, or
52		-	renewed on or after October 8, 2021 (the effective date of
53		-	Public Act 102-665) this amendatory Act of the 102nd General
54		-	Assembly shall provide coverage for pregnancy and newborn care
55		-	in accordance with 42 U.S.C. 18022(b) regarding essential
56		-	health benefits. For policies amended, delivered, issued, or
57		-	renewed on or after January 1, 2026, this subsection also
	32	+	HB5142 Enrolled- 2 -LRB103 38742 RPS 68879 b HB5142 Enrolled - 2 - LRB103 38742 RPS 68879 b
	33	+	HB5142 Enrolled - 2 - LRB103 38742 RPS 68879 b
	34	+	1 would disqualify a high-deductible health plan from
	35	+	2 eligibility for a health savings account pursuant to Section
	36	+	3 223 of the Internal Revenue Code.
	37	+	4 (c) Except as otherwise authorized under this Section, a
	38	+	5 policy shall not impose any restrictions or delays on the
	39	+	6 coverage required under this Section.
	40	+	7 (d) This Section does not, pursuant to 42 U.S.C.
	41	+	8 18054(a)(6), apply to a multistate plan that does not provide
	42	+	9 coverage for abortion.
	43	+	10 (e) If the Department concludes that enforcement of this
	44	+	11 Section may adversely affect the allocation of federal funds
	45	+	12 to this State, the Department may grant an exemption to the
	46	+	13 requirements, but only to the minimum extent necessary to
	47	+	14 ensure the continued receipt of federal funds.
	48	+	15 (Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)
	49	+	16 (215 ILCS 5/356z.40)
	50	+	17 Sec. 356z.40. Pregnancy and postpartum coverage.
	51	+	18 (a) An individual or group policy of accident and health
	52	+	19 insurance or managed care plan amended, delivered, issued, or
	53	+	20 renewed on or after October 8, 2021 (the effective date of
	54	+	21 Public Act 102-665) this amendatory Act of the 102nd General
	55	+	22 Assembly shall provide coverage for pregnancy and newborn care
	56	+	23 in accordance with 42 U.S.C. 18022(b) regarding essential
	57	+	24 health benefits. For policies amended, delivered, issued, or
	58	+	25 renewed on or after January 1, 2026, this subsection also
58	59
59	60
60		-	applies to coverage for postpartum care.
61		-	(b) Benefits under this Section shall be as follows:
62		-	(1) An individual who has been identified as
63		-	experiencing a high-risk pregnancy by the individual's
64		-	treating provider shall have access to clinically
65		-	appropriate case management programs. As used in this
66		-	subsection, "case management" means a mechanism to
67		-	coordinate and assure continuity of services, including,
68		-	but not limited to, health services, social services, and
69		-	educational services necessary for the individual. "Case
70		-	management" involves individualized assessment of needs,
71		-	planning of services, referral, monitoring, and advocacy
72		-	to assist an individual in gaining access to appropriate
73		-	services and closure when services are no longer required.
74		-	"Case management" is an active and collaborative process
75		-	involving a single qualified case manager, the individual,
76		-	the individual's family, the providers, and the community.
77		-	This includes close coordination and involvement with all
78		-	service providers in the management plan for that
79		-	individual or family, including assuring that the
80		-	individual receives the services. As used in this
81		-	subsection, "high-risk pregnancy" means a pregnancy in
82		-	which the pregnant or postpartum individual or baby is at
83		-	an increased risk for poor health or complications during
84		-	pregnancy or childbirth, including, but not limited to,
85		-	hypertension disorders, gestational diabetes, and
86	61
87	62
88		-	hemorrhage.
89		-	(2) An individual shall have access to medically
90		-	necessary treatment of a mental, emotional, nervous, or
91		-	substance use disorder or condition consistent with the
92		-	requirements set forth in this Section and in Sections
93		-	370c and 370c.1 of this Code.
94		-	(3) The benefits provided for inpatient and outpatient
95		-	services for the treatment of a mental, emotional,
96		-	nervous, or substance use disorder or condition related to
97		-	pregnancy or postpartum complications shall be provided if
98		-	determined to be medically necessary, consistent with the
99		-	requirements of Sections 370c and 370c.1 of this Code. The
100		-	facility or provider shall notify the insurer of both the
101		-	admission and the initial treatment plan within 48 hours
102		-	after admission or initiation of treatment. Nothing in
103		-	this paragraph shall prevent an insurer from applying
104		-	concurrent and post-service utilization review of health
105		-	care services, including review of medical necessity, case
106		-	management, experimental and investigational treatments,
107		-	managed care provisions, and other terms and conditions of
108		-	the insurance policy.
109		-	(4) The benefits for the first 48 hours of initiation
110		-	of services for an inpatient admission, detoxification or
111		-	withdrawal management program, or partial hospitalization
112		-	admission for the treatment of a mental, emotional,
113		-	nervous, or substance use disorder or condition related to
	63	+
	64	+	HB5142 Enrolled - 2 - LRB103 38742 RPS 68879 b
114	65
115	66
116		-	pregnancy or postpartum complications shall be provided
117		-	without post-service or concurrent review of medical
118		-	necessity, as the medical necessity for the first 48 hours
119		-	of such services shall be determined solely by the covered
120		-	pregnant or postpartum individual's provider. Nothing in
121		-	this paragraph shall prevent an insurer from applying
122		-	concurrent and post-service utilization review, including
123		-	the review of medical necessity, case management,
124		-	experimental and investigational treatments, managed care
125		-	provisions, and other terms and conditions of the
126		-	insurance policy, of any inpatient admission,
127		-	detoxification or withdrawal management program admission,
128		-	or partial hospitalization admission services for the
129		-	treatment of a mental, emotional, nervous, or substance
130		-	use disorder or condition related to pregnancy or
131		-	postpartum complications received 48 hours after the
132		-	initiation of such services. If an insurer determines that
133		-	the services are no longer medically necessary, then the
134		-	covered person shall have the right to external review
135		-	pursuant to the requirements of the Health Carrier
136		-	External Review Act.
137		-	(5) If an insurer determines that continued inpatient
138		-	care, detoxification or withdrawal management, partial
139		-	hospitalization, intensive outpatient treatment, or
140		-	outpatient treatment in a facility is no longer medically
141		-	necessary, the insurer shall, within 24 hours, provide
	67	+	HB5142 Enrolled- 3 -LRB103 38742 RPS 68879 b HB5142 Enrolled - 3 - LRB103 38742 RPS 68879 b
	68	+	HB5142 Enrolled - 3 - LRB103 38742 RPS 68879 b
	69	+	1 applies to coverage for postpartum care.
	70	+	2 (b) Benefits under this Section shall be as follows:
	71	+	3 (1) An individual who has been identified as
	72	+	4 experiencing a high-risk pregnancy by the individual's
	73	+	5 treating provider shall have access to clinically
	74	+	6 appropriate case management programs. As used in this
	75	+	7 subsection, "case management" means a mechanism to
	76	+	8 coordinate and assure continuity of services, including,
	77	+	9 but not limited to, health services, social services, and
	78	+	10 educational services necessary for the individual. "Case
	79	+	11 management" involves individualized assessment of needs,
	80	+	12 planning of services, referral, monitoring, and advocacy
	81	+	13 to assist an individual in gaining access to appropriate
	82	+	14 services and closure when services are no longer required.
	83	+	15 "Case management" is an active and collaborative process
	84	+	16 involving a single qualified case manager, the individual,
	85	+	17 the individual's family, the providers, and the community.
	86	+	18 This includes close coordination and involvement with all
	87	+	19 service providers in the management plan for that
	88	+	20 individual or family, including assuring that the
	89	+	21 individual receives the services. As used in this
	90	+	22 subsection, "high-risk pregnancy" means a pregnancy in
	91	+	23 which the pregnant or postpartum individual or baby is at
	92	+	24 an increased risk for poor health or complications during
	93	+	25 pregnancy or childbirth, including, but not limited to,
	94	+	26 hypertension disorders, gestational diabetes, and
142	95
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144		-	written notice to the covered pregnant or postpartum
145		-	individual and the covered pregnant or postpartum
146		-	individual's provider of its decision and the right to
147		-	file an expedited internal appeal of the determination.
148		-	The insurer shall review and make a determination with
149		-	respect to the internal appeal within 24 hours and
150		-	communicate such determination to the covered pregnant or
151		-	postpartum individual and the covered pregnant or
152		-	postpartum individual's provider. If the determination is
153		-	to uphold the denial, the covered pregnant or postpartum
154		-	individual and the covered pregnant or postpartum
155		-	individual's provider have the right to file an expedited
156		-	external appeal. An independent utilization review
157		-	organization shall make a determination within 72 hours.
158		-	If the insurer's determination is upheld and it is
159		-	determined that continued inpatient care, detoxification
160		-	or withdrawal management, partial hospitalization,
161		-	intensive outpatient treatment, or outpatient treatment is
162		-	not medically necessary, the insurer shall remain
163		-	responsible for providing benefits for the inpatient care,
164		-	detoxification or withdrawal management, partial
165		-	hospitalization, intensive outpatient treatment, or
166		-	outpatient treatment through the day following the date
167		-	the determination is made, and the covered pregnant or
168		-	postpartum individual shall only be responsible for any
169		-	applicable copayment, deductible, and coinsurance for the
170	97
171	98
172		-	stay through that date as applicable under the policy. The
173		-	covered pregnant or postpartum individual shall not be
174		-	discharged or released from the inpatient facility,
175		-	detoxification or withdrawal management, partial
176		-	hospitalization, intensive outpatient treatment, or
177		-	outpatient treatment until all internal appeals and
178		-	independent utilization review organization appeals are
179		-	exhausted. A decision to reverse an adverse determination
180		-	shall comply with the Health Carrier External Review Act.
181		-	(6) Except as otherwise stated in this subsection (b)
182		-	and subsection (c), the benefits and cost-sharing shall be
183		-	provided to the same extent as for any other medical
184		-	condition covered under the policy.
185		-	(7) The benefits required by paragraphs (2) and (6) of
186		-	this subsection (b) are to be provided to all covered
187		-	pregnant or postpartum individuals with a diagnosis of a
188		-	mental, emotional, nervous, or substance use disorder or
189		-	condition. The presence of additional related or unrelated
190		-	diagnoses shall not be a basis to reduce or deny the
191		-	benefits required by this subsection (b).
192		-	(8) Insurers shall cover all services for pregnancy,
193		-	postpartum, and newborn care that are rendered by
194		-	perinatal doulas or licensed certified professional
195		-	midwives, including home births, home visits, and support
196		-	during labor, abortion, or miscarriage. Coverage shall
197		-	include the necessary equipment and medical supplies for a
	99	+
	100	+	HB5142 Enrolled - 3 - LRB103 38742 RPS 68879 b
198	101
199	102
200		-	home birth. For home visits by a perinatal doula, not
201		-	counting any home birth, the policy may limit coverage to
202		-	16 visits before and 16 visits after a birth, miscarriage,
203		-	or abortion, provided that the policy shall not be
204		-	required to cover more than $8,000 for doula visits for
205		-	each pregnancy and subsequent postpartum period. As used
206		-	in this paragraph (8), "perinatal doula" has the meaning
207		-	given in subsection (a) of Section 5-18.5 of the Illinois
208		-	Public Aid Code.
209		-	(9) Coverage for pregnancy, postpartum, and newborn
210		-	care shall include home visits by lactation consultants
211		-	and the purchase of breast pumps and breast pump supplies,
212		-	including such breast pumps, breast pump supplies,
213		-	breastfeeding supplies, and feeding aids as recommended by
214		-	the lactation consultant. As used in this paragraph (9),
215		-	"lactation consultant" means an International
216		-	Board-Certified Lactation Consultant, a certified
217		-	lactation specialist with a certification from Lactation
218		-	Education Consultants, or a certified lactation counselor
219		-	as defined in subsection (a) of Section 5-18.10 of the
220		-	Illinois Public Aid Code.
221		-	(10) Coverage for postpartum services shall apply for
222		-	all covered services rendered within the first 12 months
223		-	after the end of pregnancy, subject to any policy
224		-	limitation on home visits by a perinatal doula allowed
225		-	under paragraph (8) of this subsection (b). Nothing in
	103	+	HB5142 Enrolled- 4 -LRB103 38742 RPS 68879 b HB5142 Enrolled - 4 - LRB103 38742 RPS 68879 b
	104	+	HB5142 Enrolled - 4 - LRB103 38742 RPS 68879 b
	105	+	1 hemorrhage.
	106	+	2 (2) An individual shall have access to medically
	107	+	3 necessary treatment of a mental, emotional, nervous, or
	108	+	4 substance use disorder or condition consistent with the
	109	+	5 requirements set forth in this Section and in Sections
	110	+	6 370c and 370c.1 of this Code.
	111	+	7 (3) The benefits provided for inpatient and outpatient
	112	+	8 services for the treatment of a mental, emotional,
	113	+	9 nervous, or substance use disorder or condition related to
	114	+	10 pregnancy or postpartum complications shall be provided if
	115	+	11 determined to be medically necessary, consistent with the
	116	+	12 requirements of Sections 370c and 370c.1 of this Code. The
	117	+	13 facility or provider shall notify the insurer of both the
	118	+	14 admission and the initial treatment plan within 48 hours
	119	+	15 after admission or initiation of treatment. Nothing in
	120	+	16 this paragraph shall prevent an insurer from applying
	121	+	17 concurrent and post-service utilization review of health
	122	+	18 care services, including review of medical necessity, case
	123	+	19 management, experimental and investigational treatments,
	124	+	20 managed care provisions, and other terms and conditions of
	125	+	21 the insurance policy.
	126	+	22 (4) The benefits for the first 48 hours of initiation
	127	+	23 of services for an inpatient admission, detoxification or
	128	+	24 withdrawal management program, or partial hospitalization
	129	+	25 admission for the treatment of a mental, emotional,
	130	+	26 nervous, or substance use disorder or condition related to
226	131
227	132
228		-	this paragraph (10) shall be construed to require a policy
229		-	to cover services for an individual who is no longer
230		-	insured or enrolled under the policy. If an individual
231		-	becomes insured or enrolled under a new policy, the new
232		-	policy shall cover the individual consistent with the time
233		-	period and limitations allowed under this paragraph (10).
234		-	This paragraph (10) is subject to the requirements of
235		-	Section 25 of the Managed Care Reform and Patient Rights
236		-	Act, Section 20 of the Network Adequacy and Transparency
237		-	Act, and 42 U.S.C. 300gg-113.
238		-	(c) All coverage described in subsection (b), other than
239		-	health care services for home births, shall be provided
240		-	without cost-sharing, except that, for mental health services,
241		-	the cost-sharing prohibition does not apply to inpatient or
242		-	residential services, and, for substance use disorder
243		-	services, the cost-sharing prohibition applies only to levels
244		-	of treatment below and not including Level 3.1 (Clinically
245		-	Managed Low-Intensity Residential), as established by the
246		-	American Society for Addiction Medicine. This subsection does
247		-	not apply to the extent such coverage would disqualify a
248		-	high-deductible health plan from eligibility for a health
249		-	savings account pursuant to Section 223 of the Internal
250		-	Revenue Code.
251		-	(Source: P.A. 102-665, eff. 10-8-21.)
252		-	Section 10. The Illinois Public Aid Code is amended by
253	133
254	134
255		-	changing Sections 5-16.7 and 5-18.5 as follows:
256		-	(305 ILCS 5/5-16.7)
257		-	Sec. 5-16.7. Post-parturition care. The medical assistance
258		-	program shall provide the post-parturition care benefits
259		-	required to be covered by a policy of accident and health
260		-	insurance under Section 356s of the Illinois Insurance Code.
261		-	On and after July 1, 2012, the Department shall reduce any
262		-	rate of reimbursement for services or other payments or alter
263		-	any methodologies authorized by this Code to reduce any rate
264		-	of reimbursement for services or other payments in accordance
265		-	with Section 5-5e.
266		-	(Source: P.A. 97-689, eff. 6-14-12.)
267		-	(305 ILCS 5/5-18.5)
268		-	Sec. 5-18.5. Perinatal doula and evidence-based home
269		-	visiting services.
270		-	(a) As used in this Section:
271		-	"Home visiting" means a voluntary, evidence-based strategy
272		-	used to support pregnant people, infants, and young children
273		-	and their caregivers to promote infant, child, and maternal
274		-	health, to foster educational development and school
275		-	readiness, and to help prevent child abuse and neglect. Home
276		-	visitors are trained professionals whose visits and activities
277		-	focus on promoting strong parent-child attachment to foster
278		-	healthy child development.
	135	+
	136	+	HB5142 Enrolled - 4 - LRB103 38742 RPS 68879 b
279	137
280	138
281		-	"Perinatal doula" means a trained provider who provides
282		-	regular, voluntary physical, emotional, and educational
283		-	support, but not medical or midwife care, to pregnant and
284		-	birthing persons before, during, and after childbirth,
285		-	otherwise known as the perinatal period.
286		-	"Perinatal doula training" means any doula training that
287		-	focuses on providing support throughout the prenatal, labor
288		-	and delivery, or postpartum period, and reflects the type of
289		-	doula care that the doula seeks to provide.
290		-	(b) Notwithstanding any other provision of this Article,
291		-	perinatal doula services and evidence-based home visiting
292		-	services shall be covered under the medical assistance
293		-	program, subject to appropriation, for persons who are
294		-	otherwise eligible for medical assistance under this Article.
295		-	Perinatal doula services include regular visits beginning in
296		-	the prenatal period and continuing into the postnatal period,
297		-	inclusive of continuous support during labor and delivery,
298		-	that support healthy pregnancies and positive birth outcomes.
299		-	Perinatal doula services may be embedded in an existing
300		-	program, such as evidence-based home visiting. Perinatal doula
301		-	services provided during the prenatal period may be provided
302		-	weekly, services provided during the labor and delivery period
303		-	may be provided for the entire duration of labor and the time
304		-	immediately following birth, and services provided during the
305		-	postpartum period may be provided up to 12 months postpartum.
306		-	(b-5) Notwithstanding any other provision of this Article,
	139	+	HB5142 Enrolled- 5 -LRB103 38742 RPS 68879 b HB5142 Enrolled - 5 - LRB103 38742 RPS 68879 b
	140	+	HB5142 Enrolled - 5 - LRB103 38742 RPS 68879 b
	141	+	1 pregnancy or postpartum complications shall be provided
	142	+	2 without post-service or concurrent review of medical
	143	+	3 necessity, as the medical necessity for the first 48 hours
	144	+	4 of such services shall be determined solely by the covered
	145	+	5 pregnant or postpartum individual's provider. Nothing in
	146	+	6 this paragraph shall prevent an insurer from applying
	147	+	7 concurrent and post-service utilization review, including
	148	+	8 the review of medical necessity, case management,
	149	+	9 experimental and investigational treatments, managed care
	150	+	10 provisions, and other terms and conditions of the
	151	+	11 insurance policy, of any inpatient admission,
	152	+	12 detoxification or withdrawal management program admission,
	153	+	13 or partial hospitalization admission services for the
	154	+	14 treatment of a mental, emotional, nervous, or substance
	155	+	15 use disorder or condition related to pregnancy or
	156	+	16 postpartum complications received 48 hours after the
	157	+	17 initiation of such services. If an insurer determines that
	158	+	18 the services are no longer medically necessary, then the
	159	+	19 covered person shall have the right to external review
	160	+	20 pursuant to the requirements of the Health Carrier
	161	+	21 External Review Act.
	162	+	22 (5) If an insurer determines that continued inpatient
	163	+	23 care, detoxification or withdrawal management, partial
	164	+	24 hospitalization, intensive outpatient treatment, or
	165	+	25 outpatient treatment in a facility is no longer medically
	166	+	26 necessary, the insurer shall, within 24 hours, provide
307	167
308	168
309		-	beginning January 1, 2023, licensed certified professional
310		-	midwife services and, beginning January 1, 2025, certified
311		-	professional midwife services shall be covered under the
312		-	medical assistance program, subject to appropriation, for
313		-	persons who are otherwise eligible for medical assistance
314		-	under this Article. The Department shall consult with midwives
315		-	on reimbursement rates for midwifery services.
316		-	(c) The Department of Healthcare and Family Services shall
317		-	adopt rules to administer this Section. In this rulemaking,
318		-	the Department shall consider the expertise of and consult
319		-	with doula program experts, doula training providers,
320		-	practicing doulas, and home visiting experts, along with State
321		-	agencies implementing perinatal doula services and relevant
322		-	bodies under the Illinois Early Learning Council. This body of
323		-	experts shall inform the Department on the credentials
324		-	necessary for perinatal doula and home visiting services to be
325		-	eligible for Medicaid reimbursement and the rate of
326		-	reimbursement for home visiting and perinatal doula services
327		-	in the prenatal, labor and delivery, and postpartum periods.
328		-	Every 2 years, the Department shall assess the rates of
329		-	reimbursement for perinatal doula and home visiting services
330		-	and adjust rates accordingly.
331		-	(d) The Department shall seek such State plan amendments
332		-	or waivers as may be necessary to implement this Section and
333		-	shall secure federal financial participation for expenditures
334		-	made by the Department in accordance with this Section.
335	169
336	170
337		-	(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
	171	+
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	177	+	1 written notice to the covered pregnant or postpartum
	178	+	2 individual and the covered pregnant or postpartum
	179	+	3 individual's provider of its decision and the right to
	180	+	4 file an expedited internal appeal of the determination.
	181	+	5 The insurer shall review and make a determination with
	182	+	6 respect to the internal appeal within 24 hours and
	183	+	7 communicate such determination to the covered pregnant or
	184	+	8 postpartum individual and the covered pregnant or
	185	+	9 postpartum individual's provider. If the determination is
	186	+	10 to uphold the denial, the covered pregnant or postpartum
	187	+	11 individual and the covered pregnant or postpartum
	188	+	12 individual's provider have the right to file an expedited
	189	+	13 external appeal. An independent utilization review
	190	+	14 organization shall make a determination within 72 hours.
	191	+	15 If the insurer's determination is upheld and it is
	192	+	16 determined that continued inpatient care, detoxification
	193	+	17 or withdrawal management, partial hospitalization,
	194	+	18 intensive outpatient treatment, or outpatient treatment is
	195	+	19 not medically necessary, the insurer shall remain
	196	+	20 responsible for providing benefits for the inpatient care,
	197	+	21 detoxification or withdrawal management, partial
	198	+	22 hospitalization, intensive outpatient treatment, or
	199	+	23 outpatient treatment through the day following the date
	200	+	24 the determination is made, and the covered pregnant or
	201	+	25 postpartum individual shall only be responsible for any
	202	+	26 applicable copayment, deductible, and coinsurance for the
	203	+
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	209	+
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	213	+	1 stay through that date as applicable under the policy. The
	214	+	2 covered pregnant or postpartum individual shall not be
	215	+	3 discharged or released from the inpatient facility,
	216	+	4 detoxification or withdrawal management, partial
	217	+	5 hospitalization, intensive outpatient treatment, or
	218	+	6 outpatient treatment until all internal appeals and
	219	+	7 independent utilization review organization appeals are
	220	+	8 exhausted. A decision to reverse an adverse determination
	221	+	9 shall comply with the Health Carrier External Review Act.
	222	+	10 (6) Except as otherwise stated in this subsection (b)
	223	+	11 and subsection (c), the benefits and cost-sharing shall be
	224	+	12 provided to the same extent as for any other medical
	225	+	13 condition covered under the policy.
	226	+	14 (7) The benefits required by paragraphs (2) and (6) of
	227	+	15 this subsection (b) are to be provided to all covered
	228	+	16 pregnant or postpartum individuals with a diagnosis of a
	229	+	17 mental, emotional, nervous, or substance use disorder or
	230	+	18 condition. The presence of additional related or unrelated
	231	+	19 diagnoses shall not be a basis to reduce or deny the
	232	+	20 benefits required by this subsection (b).
	233	+	21 (8) Insurers shall cover all services for pregnancy,
	234	+	22 postpartum, and newborn care that are rendered by
	235	+	23 perinatal doulas or licensed certified professional
	236	+	24 midwives, including home births, home visits, and support
	237	+	25 during labor, abortion, or miscarriage. Coverage shall
	238	+	26 include the necessary equipment and medical supplies for a
	239	+
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	241	+
	242	+
	243	+
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	245	+
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	249	+	1 home birth. For home visits by a perinatal doula, not
	250	+	2 counting any home birth, the policy may limit coverage to
	251	+	3 16 visits before and 16 visits after a birth, miscarriage,
	252	+	4 or abortion, provided that the policy shall not be
	253	+	5 required to cover more than $8,000 for doula visits for
	254	+	6 each pregnancy and subsequent postpartum period. As used
	255	+	7 in this paragraph (8), "perinatal doula" has the meaning
	256	+	8 given in subsection (a) of Section 5-18.5 of the Illinois
	257	+	9 Public Aid Code.
	258	+	10 (9) Coverage for pregnancy, postpartum, and newborn
	259	+	11 care shall include home visits by lactation consultants
	260	+	12 and the purchase of breast pumps and breast pump supplies,
	261	+	13 including such breast pumps, breast pump supplies,
	262	+	14 breastfeeding supplies, and feeding aids as recommended by
	263	+	15 the lactation consultant. As used in this paragraph (9),
	264	+	16 "lactation consultant" means an International
	265	+	17 Board-Certified Lactation Consultant, a certified
	266	+	18 lactation specialist with a certification from Lactation
	267	+	19 Education Consultants, or a certified lactation counselor
	268	+	20 as defined in subsection (a) of Section 5-18.10 of the
	269	+	21 Illinois Public Aid Code.
	270	+	22 (10) Coverage for postpartum services shall apply for
	271	+	23 all covered services rendered within the first 12 months
	272	+	24 after the end of pregnancy, subject to any policy
	273	+	25 limitation on home visits by a perinatal doula allowed
	274	+	26 under paragraph (8) of this subsection (b). Nothing in
	275	+
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	285	+	1 this paragraph (10) shall be construed to require a policy
	286	+	2 to cover services for an individual who is no longer
	287	+	3 insured or enrolled under the policy. If an individual
	288	+	4 becomes insured or enrolled under a new policy, the new
	289	+	5 policy shall cover the individual consistent with the time
	290	+	6 period and limitations allowed under this paragraph (10).
	291	+	7 This paragraph (10) is subject to the requirements of
	292	+	8 Section 25 of the Managed Care Reform and Patient Rights
	293	+	9 Act, Section 20 of the Network Adequacy and Transparency
	294	+	10 Act, and 42 U.S.C. 300gg-113.
	295	+	11 (c) All coverage described in subsection (b), other than
	296	+	12 health care services for home births, shall be provided
	297	+	13 without cost-sharing, except that, for mental health services,
	298	+	14 the cost-sharing prohibition does not apply to inpatient or
	299	+	15 residential services, and, for substance use disorder
	300	+	16 services, the cost-sharing prohibition applies only to levels
	301	+	17 of treatment below and not including Level 3.1 (Clinically
	302	+	18 Managed Low-Intensity Residential), as established by the
	303	+	19 American Society for Addiction Medicine. This subsection does
	304	+	20 not apply to the extent such coverage would disqualify a
	305	+	21 high-deductible health plan from eligibility for a health
	306	+	22 savings account pursuant to Section 223 of the Internal
	307	+	23 Revenue Code.
	308	+	24 (Source: P.A. 102-665, eff. 10-8-21.)
	309	+	25 Section 10. The Illinois Public Aid Code is amended by
	310	+
	311	+
	312	+
	313	+
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	320	+	1 changing Sections 5-16.7 and 5-18.5 as follows:
	321	+	2 (305 ILCS 5/5-16.7)
	322	+	3 Sec. 5-16.7. Post-parturition care. The medical assistance
	323	+	4 program shall provide the post-parturition care benefits
	324	+	5 required to be covered by a policy of accident and health
	325	+	6 insurance under Section 356s of the Illinois Insurance Code.
	326	+	7 On and after July 1, 2012, the Department shall reduce any
	327	+	8 rate of reimbursement for services or other payments or alter
	328	+	9 any methodologies authorized by this Code to reduce any rate
	329	+	10 of reimbursement for services or other payments in accordance
	330	+	11 with Section 5-5e.
	331	+	12 (Source: P.A. 97-689, eff. 6-14-12.)
	332	+	13 (305 ILCS 5/5-18.5)
	333	+	14 Sec. 5-18.5. Perinatal doula and evidence-based home
	334	+	15 visiting services.
	335	+	16 (a) As used in this Section:
	336	+	17 "Home visiting" means a voluntary, evidence-based strategy
	337	+	18 used to support pregnant people, infants, and young children
	338	+	19 and their caregivers to promote infant, child, and maternal
	339	+	20 health, to foster educational development and school
	340	+	21 readiness, and to help prevent child abuse and neglect. Home
	341	+	22 visitors are trained professionals whose visits and activities
	342	+	23 focus on promoting strong parent-child attachment to foster
	343	+	24 healthy child development.
	344	+
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	354	+	1 "Perinatal doula" means a trained provider who provides
	355	+	2 regular, voluntary physical, emotional, and educational
	356	+	3 support, but not medical or midwife care, to pregnant and
	357	+	4 birthing persons before, during, and after childbirth,
	358	+	5 otherwise known as the perinatal period.
	359	+	6 "Perinatal doula training" means any doula training that
	360	+	7 focuses on providing support throughout the prenatal, labor
	361	+	8 and delivery, or postpartum period, and reflects the type of
	362	+	9 doula care that the doula seeks to provide.
	363	+	10 (b) Notwithstanding any other provision of this Article,
	364	+	11 perinatal doula services and evidence-based home visiting
	365	+	12 services shall be covered under the medical assistance
	366	+	13 program, subject to appropriation, for persons who are
	367	+	14 otherwise eligible for medical assistance under this Article.
	368	+	15 Perinatal doula services include regular visits beginning in
	369	+	16 the prenatal period and continuing into the postnatal period,
	370	+	17 inclusive of continuous support during labor and delivery,
	371	+	18 that support healthy pregnancies and positive birth outcomes.
	372	+	19 Perinatal doula services may be embedded in an existing
	373	+	20 program, such as evidence-based home visiting. Perinatal doula
	374	+	21 services provided during the prenatal period may be provided
	375	+	22 weekly, services provided during the labor and delivery period
	376	+	23 may be provided for the entire duration of labor and the time
	377	+	24 immediately following birth, and services provided during the
	378	+	25 postpartum period may be provided up to 12 months postpartum.
	379	+	26 (b-5) Notwithstanding any other provision of this Article,
	380	+
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	390	+	1 beginning January 1, 2023, licensed certified professional
	391	+	2 midwife services and, beginning January 1, 2025, certified
	392	+	3 professional midwife services shall be covered under the
	393	+	4 medical assistance program, subject to appropriation, for
	394	+	5 persons who are otherwise eligible for medical assistance
	395	+	6 under this Article. The Department shall consult with midwives
	396	+	7 on reimbursement rates for midwifery services.
	397	+	8 (c) The Department of Healthcare and Family Services shall
	398	+	9 adopt rules to administer this Section. In this rulemaking,
	399	+	10 the Department shall consider the expertise of and consult
	400	+	11 with doula program experts, doula training providers,
	401	+	12 practicing doulas, and home visiting experts, along with State
	402	+	13 agencies implementing perinatal doula services and relevant
	403	+	14 bodies under the Illinois Early Learning Council. This body of
	404	+	15 experts shall inform the Department on the credentials
	405	+	16 necessary for perinatal doula and home visiting services to be
	406	+	17 eligible for Medicaid reimbursement and the rate of
	407	+	18 reimbursement for home visiting and perinatal doula services
	408	+	19 in the prenatal, labor and delivery, and postpartum periods.
	409	+	20 Every 2 years, the Department shall assess the rates of
	410	+	21 reimbursement for perinatal doula and home visiting services
	411	+	22 and adjust rates accordingly.
	412	+	23 (d) The Department shall seek such State plan amendments
	413	+	24 or waivers as may be necessary to implement this Section and
	414	+	25 shall secure federal financial participation for expenditures
	415	+	26 made by the Department in accordance with this Section.
	416	+
	417	+
	418	+
	419	+
	420	+
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	422	+
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	425	+	HB5142 Enrolled - 13 - LRB103 38742 RPS 68879 b
	426	+	1 (Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
	427	+
	428	+
	429	+
	430	+
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