HB5142 EngrossedLRB103 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 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
9individual or group policy of accident and health insurance
10that provides pregnancy-related benefits may be issued,
11amended, delivered, or renewed in this State after the
12effective date of this amendatory Act of the 101st General
13Assembly unless the policy provides a covered person with
14coverage for abortion care. Regardless of whether the policy
15otherwise provides prescription drug benefits, abortion care
16coverage must include medications that are obtained through a
17prescription and used to terminate a pregnancy, regardless of
18whether there is proof of a pregnancy.
19    (b) Coverage for abortion care may not impose any
20deductible, coinsurance, waiting period, or other cost-sharing
21limitation that is greater than that required for other
22pregnancy-related benefits covered by the policy. This
23subsection does not apply to the extent that such coverage

 

 

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1would disqualify a high-deductible health plan from
2eligibility for a health savings account pursuant to Section
3223 of the Internal Revenue Code.
4    (c) Except as otherwise authorized under this Section, a
5policy shall not impose any restrictions or delays on the
6coverage required under this Section.
7    (d) This Section does not, pursuant to 42 U.S.C.
818054(a)(6), apply to a multistate plan that does not provide
9coverage for abortion.
10    (e) If the Department concludes that enforcement of this
11Section may adversely affect the allocation of federal funds
12to this State, the Department may grant an exemption to the
13requirements, but only to the minimum extent necessary to
14ensure 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
19insurance or managed care plan amended, delivered, issued, or
20renewed on or after October 8, 2021 (the effective date of
21Public Act 102-665) this amendatory Act of the 102nd General
22Assembly shall provide coverage for pregnancy and newborn care
23in accordance with 42 U.S.C. 18022(b) regarding essential
24health benefits. For policies amended, delivered, issued, or
25renewed on or after January 1, 2026, this subsection also

 

 

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1applies 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
12health care services for home births, shall be provided
13without cost-sharing, except that, for mental health services,
14the cost-sharing prohibition does not apply to inpatient or
15residential services, and, for substance use disorder
16services, the cost-sharing prohibition applies only to levels
17of treatment below and not including Level 3.1 (Clinically
18Managed Low-Intensity Residential), as established by the
19American Society for Addiction Medicine. This subsection does
20not apply to the extent such coverage would disqualify a
21high-deductible health plan from eligibility for a health
22savings account pursuant to Section 223 of the Internal
23Revenue 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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1changing 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
4program shall provide the post-parturition care benefits
5required to be covered by a policy of accident and health
6insurance under Section 356s of the Illinois Insurance Code.
7    On and after July 1, 2012, the Department shall reduce any
8rate of reimbursement for services or other payments or alter
9any methodologies authorized by this Code to reduce any rate
10of reimbursement for services or other payments in accordance
11with 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
15visiting services.
16    (a) As used in this Section:
17    "Home visiting" means a voluntary, evidence-based strategy
18used to support pregnant people, infants, and young children
19and their caregivers to promote infant, child, and maternal
20health, to foster educational development and school
21readiness, and to help prevent child abuse and neglect. Home
22visitors are trained professionals whose visits and activities
23focus on promoting strong parent-child attachment to foster
24healthy child development.

 

 

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1    "Perinatal doula" means a trained provider who provides
2regular, voluntary physical, emotional, and educational
3support, but not medical or midwife care, to pregnant and
4birthing persons before, during, and after childbirth,
5otherwise known as the perinatal period.
6    "Perinatal doula training" means any doula training that
7focuses on providing support throughout the prenatal, labor
8and delivery, or postpartum period, and reflects the type of
9doula care that the doula seeks to provide.
10    (b) Notwithstanding any other provision of this Article,
11perinatal doula services and evidence-based home visiting
12services shall be covered under the medical assistance
13program, subject to appropriation, for persons who are
14otherwise eligible for medical assistance under this Article.
15Perinatal doula services include regular visits beginning in
16the prenatal period and continuing into the postnatal period,
17inclusive of continuous support during labor and delivery,
18that support healthy pregnancies and positive birth outcomes.
19Perinatal doula services may be embedded in an existing
20program, such as evidence-based home visiting. Perinatal doula
21services provided during the prenatal period may be provided
22weekly, services provided during the labor and delivery period
23may be provided for the entire duration of labor and the time
24immediately following birth, and services provided during the
25postpartum period may be provided up to 12 months postpartum.
26    (b-5) Notwithstanding any other provision of this Article,

 

 

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1beginning January 1, 2025 2023, licensed certified
2professional midwife services shall be covered under the
3medical assistance program, subject to appropriation, for
4persons who are otherwise eligible for medical assistance
5under this Article. The Department shall consult with midwives
6on reimbursement rates for midwifery services.
7    (c) The Department of Healthcare and Family Services shall
8adopt rules to administer this Section. In this rulemaking,
9the Department shall consider the expertise of and consult
10with doula program experts, doula training providers,
11practicing doulas, and home visiting experts, along with State
12agencies implementing perinatal doula services and relevant
13bodies under the Illinois Early Learning Council. This body of
14experts shall inform the Department on the credentials
15necessary for perinatal doula and home visiting services to be
16eligible for Medicaid reimbursement and the rate of
17reimbursement for home visiting and perinatal doula services
18in the prenatal, labor and delivery, and postpartum periods.
19Every 2 years, the Department shall assess the rates of
20reimbursement for perinatal doula and home visiting services
21and adjust rates accordingly.
22    (d) The Department shall seek such State plan amendments
23or waivers as may be necessary to implement this Section and
24shall secure federal financial participation for expenditures
25made 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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1    Section 99. Effective date. This Act takes effect January
21, 2026, except that this Section and the changes to Section
35-18.5 of the Illinois Public Aid Code take effect January 1,
42025.