103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5142

 

Introduced 2/9/2024, by Rep. Robyn Gabel

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.40
305 ILCS 5/5-16.7
305 ILCS 5/5-18.5
305 ILCS 5/5-18.10

    Amends the Illinois Insurance Code. Provides that insurers shall cover all services for pregnancy, postpartum, and newborn care that are rendered by perinatal doulas or licensed certified professional midwives, including home births, home visits, and support during labor, abortion, or miscarriage. Provides that the required coverage includes the necessary equipment and medical supplies for a home birth. Provides that coverage for pregnancy, postpartum, and newborn care shall include home visits by lactation consultants and the purchase of breast pumps and breast pump supplies, including such breast pumps, breast pump supplies, breastfeeding supplies, and feeding aides as recommended by the lactation consultant. Provides that coverage for postpartum services shall apply for at least one year after birth. Provides that certain pregnancy and postpartum coverage shall be provided without cost-sharing requirements. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that post-parturition care benefits shall not be subject to any cost-sharing requirement. Provides that the medical assistance program shall cover home visits for lactation counseling and support services. Provides that the medical assistance program shall cover counselor-recommended or provider-recommended breast pumps as well as breast pump supplies, breastfeeding supplies, and feeding aides. Provides that nothing in the provisions shall limit the number of lactation encounters, visits, or services; breast pumps; breast pump supplies; breastfeeding supplies; or feeding aides a beneficiary is entitled to receive under the program. Makes other changes. Effective January 1, 2026.


LRB103 38742 RPS 68879 b

 

 

A BILL FOR

 

HB5142LRB103 38742 RPS 68879 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.40 as follows:
 
6    (215 ILCS 5/356z.40)
7    Sec. 356z.40. Pregnancy and postpartum coverage.
8    (a) An individual or group policy of accident and health
9insurance or managed care plan amended, delivered, issued, or
10renewed on or after the effective date of this amendatory Act
11of the 103rd General Assembly this amendatory Act of the 102nd
12General Assembly shall provide coverage for pregnancy,
13postpartum, and newborn care in accordance with 42 U.S.C.
1418022(b) regarding essential health benefits.
15    (b) Benefits under this Section shall be as follows:
16        (1) An individual who has been identified as
17    experiencing a high-risk pregnancy by the individual's
18    treating provider shall have access to clinically
19    appropriate case management programs. As used in this
20    subsection, "case management" means a mechanism to
21    coordinate and assure continuity of services, including,
22    but not limited to, health services, social services, and
23    educational services necessary for the individual. "Case

 

 

HB5142- 2 -LRB103 38742 RPS 68879 b

1    management" involves individualized assessment of needs,
2    planning of services, referral, monitoring, and advocacy
3    to assist an individual in gaining access to appropriate
4    services and closure when services are no longer required.
5    "Case management" is an active and collaborative process
6    involving a single qualified case manager, the individual,
7    the individual's family, the providers, and the community.
8    This includes close coordination and involvement with all
9    service providers in the management plan for that
10    individual or family, including assuring that the
11    individual receives the services. As used in this
12    subsection, "high-risk pregnancy" means a pregnancy in
13    which the pregnant or postpartum individual or baby is at
14    an increased risk for poor health or complications during
15    pregnancy or childbirth, including, but not limited to,
16    hypertension disorders, gestational diabetes, and
17    hemorrhage.
18        (2) An individual shall have access to medically
19    necessary treatment of a mental, emotional, nervous, or
20    substance use disorder or condition consistent with the
21    requirements set forth in this Section and in Sections
22    370c and 370c.1 of this Code.
23        (3) The benefits provided for inpatient and outpatient
24    services for the treatment of a mental, emotional,
25    nervous, or substance use disorder or condition related to
26    pregnancy or postpartum complications shall be provided if

 

 

HB5142- 3 -LRB103 38742 RPS 68879 b

1    determined to be medically necessary, consistent with the
2    requirements of Sections 370c and 370c.1 of this Code. The
3    facility or provider shall notify the insurer of both the
4    admission and the initial treatment plan within 48 hours
5    after admission or initiation of treatment. Nothing in
6    this paragraph shall prevent an insurer from applying
7    concurrent and post-service utilization review of health
8    care services, including review of medical necessity, case
9    management, experimental and investigational treatments,
10    managed care provisions, and other terms and conditions of
11    the insurance policy.
12        (4) The benefits for the first 48 hours of initiation
13    of services for an inpatient admission, detoxification or
14    withdrawal management program, or partial hospitalization
15    admission for the treatment of a mental, emotional,
16    nervous, or substance use disorder or condition related to
17    pregnancy or postpartum complications shall be provided
18    without post-service or concurrent review of medical
19    necessity, as the medical necessity for the first 48 hours
20    of such services shall be determined solely by the covered
21    pregnant or postpartum individual's provider. Nothing in
22    this paragraph shall prevent an insurer from applying
23    concurrent and post-service utilization review, including
24    the review of medical necessity, case management,
25    experimental and investigational treatments, managed care
26    provisions, and other terms and conditions of the

 

 

HB5142- 4 -LRB103 38742 RPS 68879 b

1    insurance policy, of any inpatient admission,
2    detoxification or withdrawal management program admission,
3    or partial hospitalization admission services for the
4    treatment of a mental, emotional, nervous, or substance
5    use disorder or condition related to pregnancy or
6    postpartum complications received 48 hours after the
7    initiation of such services. If an insurer determines that
8    the services are no longer medically necessary, then the
9    covered person shall have the right to external review
10    pursuant to the requirements of the Health Carrier
11    External Review Act.
12        (5) If an insurer determines that continued inpatient
13    care, detoxification or withdrawal management, partial
14    hospitalization, intensive outpatient treatment, or
15    outpatient treatment in a facility is no longer medically
16    necessary, the insurer shall, within 24 hours, provide
17    written notice to the covered pregnant or postpartum
18    individual and the covered pregnant or postpartum
19    individual's provider of its decision and the right to
20    file an expedited internal appeal of the determination.
21    The insurer shall review and make a determination with
22    respect to the internal appeal within 24 hours and
23    communicate such determination to the covered pregnant or
24    postpartum individual and the covered pregnant or
25    postpartum individual's provider. If the determination is
26    to uphold the denial, the covered pregnant or postpartum

 

 

HB5142- 5 -LRB103 38742 RPS 68879 b

1    individual and the covered pregnant or postpartum
2    individual's provider have the right to file an expedited
3    external appeal. An independent utilization review
4    organization shall make a determination within 72 hours.
5    If the insurer's determination is upheld and it is
6    determined that continued inpatient care, detoxification
7    or withdrawal management, partial hospitalization,
8    intensive outpatient treatment, or outpatient treatment is
9    not medically necessary, the insurer shall remain
10    responsible for providing benefits for the inpatient care,
11    detoxification or withdrawal management, partial
12    hospitalization, intensive outpatient treatment, or
13    outpatient treatment through the day following the date
14    the determination is made, and the covered pregnant or
15    postpartum individual shall only be responsible for any
16    applicable copayment, deductible, and coinsurance for the
17    stay through that date as applicable under the policy. The
18    covered pregnant or postpartum individual shall not be
19    discharged or released from the inpatient facility,
20    detoxification or withdrawal management, partial
21    hospitalization, intensive outpatient treatment, or
22    outpatient treatment until all internal appeals and
23    independent utilization review organization appeals are
24    exhausted. A decision to reverse an adverse determination
25    shall comply with the Health Carrier External Review Act.
26        (6) Except as otherwise stated in this subsection (b),

 

 

HB5142- 6 -LRB103 38742 RPS 68879 b

1    the benefits and cost-sharing shall be provided to the
2    same extent as for any other medical condition covered
3    under the policy.
4        (7) The benefits required by paragraphs (2) and (6) of
5    this subsection (b) are to be provided to all covered
6    pregnant or postpartum individuals with a diagnosis of a
7    mental, emotional, nervous, or substance use disorder or
8    condition. The presence of additional related or unrelated
9    diagnoses shall not be a basis to reduce or deny the
10    benefits required by this subsection (b).
11        (8) Insurers shall cover all services for pregnancy,
12    postpartum, and newborn care that are rendered by
13    perinatal doulas or licensed certified professional
14    midwives, including home births, home visits, and support
15    during labor, abortion, or miscarriage. Coverage shall
16    include the necessary equipment and medical supplies for a
17    home birth.
18        (9) Coverage for pregnancy, postpartum, and newborn
19    care shall include home visits by lactation consultants
20    and the purchase of breast pumps and breast pump supplies,
21    including such breast pumps, breast pump supplies,
22    breastfeeding supplies, and feeding aides as recommended
23    by the lactation consultant.
24        (10) Coverage for postpartum services shall apply for
25    at least one year after birth.
26    (c) All coverage required under this Section shall be

 

 

HB5142- 7 -LRB103 38742 RPS 68879 b

1provided without cost sharing. This subsection does not apply
2to the extent such coverage would disqualify a high-deductible
3health plan from eligibility for a health savings account
4pursuant to Section 223 of the Internal Revenue Code.
5(Source: P.A. 102-665, eff. 10-8-21.)
 
6    Section 10. The Illinois Public Aid Code is amended by
7changing Sections 5-16.7, 5-18.5, and 5-18.10 as follows:
 
8    (305 ILCS 5/5-16.7)
9    Sec. 5-16.7. Post-parturition care. The medical assistance
10program shall provide the post-parturition care benefits
11required to be covered by a policy of accident and health
12insurance under Section 356s of the Illinois Insurance Code.
13Benefits provided under this Section shall not be subject to
14any cost-sharing requirement.
15    On and after July 1, 2012, the Department shall reduce any
16rate of reimbursement for services or other payments or alter
17any methodologies authorized by this Code to reduce any rate
18of reimbursement for services or other payments in accordance
19with Section 5-5e.
20(Source: P.A. 97-689, eff. 6-14-12.)
 
21    (305 ILCS 5/5-18.5)
22    Sec. 5-18.5. Perinatal doula and evidence-based home
23visiting services.

 

 

HB5142- 8 -LRB103 38742 RPS 68879 b

1    (a) As used in this Section:
2    "Home visiting" means a voluntary, evidence-based strategy
3used to support pregnant people, infants, and young children
4and their caregivers to promote infant, child, and maternal
5health, to foster educational development and school
6readiness, and to help prevent child abuse and neglect. Home
7visitors are trained professionals whose visits and activities
8focus on promoting strong parent-child attachment to foster
9healthy child development.
10    "Perinatal doula" means a trained provider who provides
11regular, voluntary physical, emotional, and educational
12support, but not medical or midwife care, to pregnant and
13birthing persons before, during, and after childbirth,
14otherwise known as the perinatal period.
15    "Perinatal doula training" means any doula training that
16focuses on providing support throughout the prenatal, labor
17and delivery, or postpartum period, and reflects the type of
18doula care that the doula seeks to provide.
19    (b) Notwithstanding any other provision of this Article,
20perinatal doula services and evidence-based home visiting
21services shall be covered under the medical assistance
22program, subject to appropriation, for persons who are
23otherwise eligible for medical assistance under this Article.
24Perinatal doula services include regular visits beginning in
25the prenatal period and continuing into the postnatal period,
26inclusive of continuous support during labor and delivery,

 

 

HB5142- 9 -LRB103 38742 RPS 68879 b

1that support healthy pregnancies and positive birth outcomes.
2Perinatal doula services may be embedded in an existing
3program, such as evidence-based home visiting. Perinatal doula
4services provided during the prenatal period may be provided
5weekly, services provided during the labor and delivery period
6may be provided for the entire duration of labor and the time
7immediately following birth, and services provided during the
8postpartum period may be provided up to 12 months postpartum.
9    (b-5) Notwithstanding any other provision of this Article,
10beginning January 1, 2023, licensed certified professional
11midwife services shall be covered under the medical assistance
12program, subject to appropriation, for persons who are
13otherwise eligible for medical assistance under this Article.
14The Department shall consult with midwives on reimbursement
15rates for midwifery services. Midwifery services covered under
16this subsection shall include home births and home prenatal,
17labor and delivery, and postnatal care.
18    (c) The Department of Healthcare and Family Services shall
19adopt rules to administer this Section. In this rulemaking,
20the Department shall consider the expertise of and consult
21with doula program experts, doula training providers,
22practicing doulas, and home visiting experts, along with State
23agencies implementing perinatal doula services and relevant
24bodies under the Illinois Early Learning Council. This body of
25experts shall inform the Department on the credentials
26necessary for perinatal doula and home visiting services to be

 

 

HB5142- 10 -LRB103 38742 RPS 68879 b

1eligible for Medicaid reimbursement and the rate of
2reimbursement for home visiting and perinatal doula services
3in the prenatal, labor and delivery, and postpartum periods.
4Every 2 years, the Department shall assess the rates of
5reimbursement for perinatal doula and home visiting services
6and adjust rates accordingly.
7    (d) The Department shall seek such State plan amendments
8or waivers as may be necessary to implement this Section and
9shall secure federal financial participation for expenditures
10made by the Department in accordance with this Section.
11(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
 
12    (305 ILCS 5/5-18.10)
13    Sec. 5-18.10. Reimbursement for postpartum visits.
14    (a) In this Section:
15    "Certified lactation counselor" means a health care
16professional in lactation counseling who has demonstrated the
17necessary skills, knowledge, and attitudes to provide clinical
18breastfeeding counseling and management support to families
19who are thinking about breastfeeding or who have questions or
20problems during the course of breastfeeding.
21    "Certified nurse midwife" means a person who exceeds the
22competencies for a midwife contained in the Essential
23Competencies for Midwifery Practice, published by the
24International Confederation of Midwives, and who qualifies as
25an advanced practice registered nurse.

 

 

HB5142- 11 -LRB103 38742 RPS 68879 b

1    "Community health worker" means a frontline public health
2worker who is a trusted member or has an unusually close
3understanding of the community served. This trusting
4relationship enables the community health worker to serve as a
5liaison, link, and intermediary between health and social
6services and the community to facilitate access to services
7and improve the quality and cultural competence of service
8delivery.
9    "International board-certified lactation consultant"
10means a health care professional who is certified by the
11International Board of Lactation Consultant Examiners and
12specializes in the clinical management of breastfeeding.
13    "Medical caseworker" means a health care professional who
14assists in the planning, coordination, monitoring, and
15evaluation of medical services for a patient with emphasis on
16quality of care, continuity of services, and affordability.
17    "Perinatal doula" means a trained provider of regular and
18voluntary physical, emotional, and educational support, but
19not medical or midwife care, to pregnant and birthing persons
20before, during, and after childbirth, otherwise known as the
21perinatal period.
22    "Public health nurse" means a registered nurse who
23promotes and protects the health of populations using
24knowledge from nursing, social, and public health sciences.
25    (b) The Illinois Department shall establish a medical
26assistance program to cover a universal postpartum visit

 

 

HB5142- 12 -LRB103 38742 RPS 68879 b

1within the first 3 weeks after childbirth and a comprehensive
2visit within 4 to 12 weeks postpartum for persons who are
3otherwise eligible for medical assistance under this Article.
4In addition, postpartum care services rendered by perinatal
5doulas, certified lactation counselors, international
6board-certified lactation consultants, public health nurses,
7certified nurse midwives, community health workers, and
8medical caseworkers shall be covered under the medical
9assistance program.
10    (c) The medical assistance program shall cover home visits
11for lactation counseling and support services. Visits may
12occur before birth and at any time within 12 months
13postpartum.
14    (d) The medical assistance program shall cover
15counselor-recommended or provider-recommended breast pumps as
16well as breast pump supplies, breastfeeding supplies, and
17feeding aides.
18    (e) Nothing in this Section shall limit the number of
19lactation encounters, visits, or services; breast pumps;
20breast pump supplies; breastfeeding supplies; or feeding aides
21a beneficiary is entitled to receive under the medical
22assistance program.
23(Source: P.A. 102-665, eff. 10-8-21.)
 
24    Section 99. Effective date. This Act takes effect January
251, 2026.