Rep. Robyn Gabel

Filed: 4/15/2024

 

 


 

 


 
10300HB5142ham005LRB103 38742 RPS 72370 a

1
AMENDMENT TO HOUSE BILL 5142

2    AMENDMENT NO. ______. Amend House Bill 5142, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Illinois Insurance Code is amended by
6changing Sections 356z.4a and 356z.40 as follows:
 
7    (215 ILCS 5/356z.4a)
8    Sec. 356z.4a. Coverage for abortion.
9    (a) Except as otherwise provided in this Section, no
10individual or group policy of accident and health insurance
11that provides pregnancy-related benefits may be issued,
12amended, delivered, or renewed in this State after the
13effective date of this amendatory Act of the 101st General
14Assembly unless the policy provides a covered person with
15coverage for abortion care. Regardless of whether the policy
16otherwise provides prescription drug benefits, abortion care

 

 

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1coverage must include medications that are obtained through a
2prescription and used to terminate a pregnancy, regardless of
3whether there is proof of a pregnancy.
4    (b) Coverage for abortion care may not impose any
5deductible, coinsurance, waiting period, or other cost-sharing
6limitation that is greater than that required for other
7pregnancy-related benefits covered by the policy. This
8subsection does not apply to the extent that such coverage
9would disqualify a high-deductible health plan from
10eligibility for a health savings account pursuant to Section
11223 of the Internal Revenue Code.
12    (c) Except as otherwise authorized under this Section, a
13policy shall not impose any restrictions or delays on the
14coverage required under this Section.
15    (d) This Section does not, pursuant to 42 U.S.C.
1618054(a)(6), apply to a multistate plan that does not provide
17coverage for abortion.
18    (e) If the Department concludes that enforcement of this
19Section may adversely affect the allocation of federal funds
20to this State, the Department may grant an exemption to the
21requirements, but only to the minimum extent necessary to
22ensure the continued receipt of federal funds.
23(Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)
 
24    (215 ILCS 5/356z.40)
25    Sec. 356z.40. Pregnancy and postpartum coverage.

 

 

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1    (a) An individual or group policy of accident and health
2insurance or managed care plan amended, delivered, issued, or
3renewed on or after October 8, 2021 (the effective date of
4Public Act 102-665) this amendatory Act of the 102nd General
5Assembly shall provide coverage for pregnancy and newborn care
6in accordance with 42 U.S.C. 18022(b) regarding essential
7health benefits. For policies amended, delivered, issued, or
8renewed on or after January 1, 2026, this subsection also
9applies to coverage for postpartum care.
10    (b) Benefits under this Section shall be as follows:
11        (1) An individual who has been identified as
12    experiencing a high-risk pregnancy by the individual's
13    treating provider shall have access to clinically
14    appropriate case management programs. As used in this
15    subsection, "case management" means a mechanism to
16    coordinate and assure continuity of services, including,
17    but not limited to, health services, social services, and
18    educational services necessary for the individual. "Case
19    management" involves individualized assessment of needs,
20    planning of services, referral, monitoring, and advocacy
21    to assist an individual in gaining access to appropriate
22    services and closure when services are no longer required.
23    "Case management" is an active and collaborative process
24    involving a single qualified case manager, the individual,
25    the individual's family, the providers, and the community.
26    This includes close coordination and involvement with all

 

 

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1    service providers in the management plan for that
2    individual or family, including assuring that the
3    individual receives the services. As used in this
4    subsection, "high-risk pregnancy" means a pregnancy in
5    which the pregnant or postpartum individual or baby is at
6    an increased risk for poor health or complications during
7    pregnancy or childbirth, including, but not limited to,
8    hypertension disorders, gestational diabetes, and
9    hemorrhage.
10        (2) An individual shall have access to medically
11    necessary treatment of a mental, emotional, nervous, or
12    substance use disorder or condition consistent with the
13    requirements set forth in this Section and in Sections
14    370c and 370c.1 of this Code.
15        (3) The benefits provided for inpatient and outpatient
16    services for the treatment of a mental, emotional,
17    nervous, or substance use disorder or condition related to
18    pregnancy or postpartum complications shall be provided if
19    determined to be medically necessary, consistent with the
20    requirements of Sections 370c and 370c.1 of this Code. The
21    facility or provider shall notify the insurer of both the
22    admission and the initial treatment plan within 48 hours
23    after admission or initiation of treatment. Nothing in
24    this paragraph shall prevent an insurer from applying
25    concurrent and post-service utilization review of health
26    care services, including review of medical necessity, case

 

 

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1    management, experimental and investigational treatments,
2    managed care provisions, and other terms and conditions of
3    the insurance policy.
4        (4) The benefits for the first 48 hours of initiation
5    of services for an inpatient admission, detoxification or
6    withdrawal management program, or partial hospitalization
7    admission for the treatment of a mental, emotional,
8    nervous, or substance use disorder or condition related to
9    pregnancy or postpartum complications shall be provided
10    without post-service or concurrent review of medical
11    necessity, as the medical necessity for the first 48 hours
12    of such services shall be determined solely by the covered
13    pregnant or postpartum individual's provider. Nothing in
14    this paragraph shall prevent an insurer from applying
15    concurrent and post-service utilization review, including
16    the review of medical necessity, case management,
17    experimental and investigational treatments, managed care
18    provisions, and other terms and conditions of the
19    insurance policy, of any inpatient admission,
20    detoxification or withdrawal management program admission,
21    or partial hospitalization admission services for the
22    treatment of a mental, emotional, nervous, or substance
23    use disorder or condition related to pregnancy or
24    postpartum complications received 48 hours after the
25    initiation of such services. If an insurer determines that
26    the services are no longer medically necessary, then the

 

 

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1    covered person shall have the right to external review
2    pursuant to the requirements of the Health Carrier
3    External Review Act.
4        (5) If an insurer determines that continued inpatient
5    care, detoxification or withdrawal management, partial
6    hospitalization, intensive outpatient treatment, or
7    outpatient treatment in a facility is no longer medically
8    necessary, the insurer shall, within 24 hours, provide
9    written notice to the covered pregnant or postpartum
10    individual and the covered pregnant or postpartum
11    individual's provider of its decision and the right to
12    file an expedited internal appeal of the determination.
13    The insurer shall review and make a determination with
14    respect to the internal appeal within 24 hours and
15    communicate such determination to the covered pregnant or
16    postpartum individual and the covered pregnant or
17    postpartum individual's provider. If the determination is
18    to uphold the denial, the covered pregnant or postpartum
19    individual and the covered pregnant or postpartum
20    individual's provider have the right to file an expedited
21    external appeal. An independent utilization review
22    organization shall make a determination within 72 hours.
23    If the insurer's determination is upheld and it is
24    determined that continued inpatient care, detoxification
25    or withdrawal management, partial hospitalization,
26    intensive outpatient treatment, or outpatient treatment is

 

 

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1    not medically necessary, the insurer shall remain
2    responsible for providing benefits for the inpatient care,
3    detoxification or withdrawal management, partial
4    hospitalization, intensive outpatient treatment, or
5    outpatient treatment through the day following the date
6    the determination is made, and the covered pregnant or
7    postpartum individual shall only be responsible for any
8    applicable copayment, deductible, and coinsurance for the
9    stay through that date as applicable under the policy. The
10    covered pregnant or postpartum individual shall not be
11    discharged or released from the inpatient facility,
12    detoxification or withdrawal management, partial
13    hospitalization, intensive outpatient treatment, or
14    outpatient treatment until all internal appeals and
15    independent utilization review organization appeals are
16    exhausted. A decision to reverse an adverse determination
17    shall comply with the Health Carrier External Review Act.
18        (6) Except as otherwise stated in this subsection (b)
19    and subsection (c), the benefits and cost-sharing shall be
20    provided to the same extent as for any other medical
21    condition covered under the policy.
22        (7) The benefits required by paragraphs (2) and (6) of
23    this subsection (b) are to be provided to all covered
24    pregnant or postpartum individuals with a diagnosis of a
25    mental, emotional, nervous, or substance use disorder or
26    condition. The presence of additional related or unrelated

 

 

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1    diagnoses shall not be a basis to reduce or deny the
2    benefits required by this subsection (b).
3        (8) Insurers shall cover all services for pregnancy,
4    postpartum, and newborn care that are rendered by
5    perinatal doulas or licensed certified professional
6    midwives, including home births, home visits, and support
7    during labor, abortion, or miscarriage. Coverage shall
8    include the necessary equipment and medical supplies for a
9    home birth. For home visits by a perinatal doula, not
10    counting any home birth, the policy may limit coverage to
11    16 visits before and 16 visits after a birth, miscarriage,
12    or abortion, provided that the policy shall not be
13    required to cover more than $8,000 for doula visits for
14    each pregnancy and subsequent postpartum period. As used
15    in this paragraph (8), "perinatal doula" has the meaning
16    given in subsection (a) of Section 5-18.5 of the Illinois
17    Public Aid Code.
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. As used in this paragraph
24    (9), "lactation consultant" means an International
25    Board-Certified Lactation Consultant, a certified
26    lactation specialist with a certification from Lactation

 

 

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1    Education Consultants, or a certified lactation counselor
2    as defined in subsection (a) of Section 5-18.10 of the
3    Illinois Public Aid Code.
4        (10) Coverage for postpartum services shall apply for
5    all covered services rendered within the first 12 months
6    after the end of pregnancy, subject to any policy
7    limitation on home visits by a perinatal doula allowed
8    under paragraph (8) of this subsection (b). Nothing in
9    this paragraph (10) shall be construed to require a policy
10    to cover services for an individual who is no longer
11    insured or enrolled under the policy. If an individual
12    becomes insured or enrolled under a new policy, the new
13    policy shall cover the individual consistent with the time
14    period and limitations allowed under this paragraph (10).
15    This paragraph (10) is subject to the requirements of
16    Section 25 of the Managed Care Reform and Patient Rights
17    Act, Section 20 of the Network Adequacy and Transparency
18    Act, and 42 U.S.C. 300gg-113.
19    (c) All coverage described in subsection (b), other than
20health care services for home births, shall be provided
21without cost-sharing, except that, for mental health services,
22the cost-sharing prohibition does not apply to inpatient or
23residential services, and, for substance use disorder
24services, the cost-sharing prohibition applies only to levels
25of treatment below and not including Level 3.1 (Clinically
26Managed Low-Intensity Residential), as established by the

 

 

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1American Society for Addiction Medicine. This subsection does
2not apply to the extent such coverage would disqualify a
3high-deductible health plan from eligibility for a health
4savings account pursuant to Section 223 of the Internal
5Revenue Code.
6(Source: P.A. 102-665, eff. 10-8-21.)
 
7    Section 10. The Illinois Public Aid Code is amended by
8changing Sections 5-16.7 and 5-18.5 as follows:
 
9    (305 ILCS 5/5-16.7)
10    Sec. 5-16.7. Post-parturition care. The medical assistance
11program shall provide the post-parturition care benefits
12required to be covered by a policy of accident and health
13insurance under Section 356s of the Illinois Insurance Code.
14    On and after July 1, 2012, the Department shall reduce any
15rate of reimbursement for services or other payments or alter
16any methodologies authorized by this Code to reduce any rate
17of reimbursement for services or other payments in accordance
18with Section 5-5e.
19(Source: P.A. 97-689, eff. 6-14-12.)
 
20    (305 ILCS 5/5-18.5)
21    Sec. 5-18.5. Perinatal doula and evidence-based home
22visiting services.
23    (a) As used in this Section:

 

 

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

 

 

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1Perinatal doula services may be embedded in an existing
2program, such as evidence-based home visiting. Perinatal doula
3services provided during the prenatal period may be provided
4weekly, services provided during the labor and delivery period
5may be provided for the entire duration of labor and the time
6immediately following birth, and services provided during the
7postpartum period may be provided up to 12 months postpartum.
8    (b-5) Notwithstanding any other provision of this Article,
9beginning January 1, 2025 2023, licensed certified
10professional midwife services shall be covered under the
11medical assistance program, subject to appropriation, for
12persons who are otherwise eligible for medical assistance
13under this Article. The Department shall consult with midwives
14on reimbursement rates for midwifery services.
15    (c) The Department of Healthcare and Family Services shall
16adopt rules to administer this Section. In this rulemaking,
17the Department shall consider the expertise of and consult
18with doula program experts, doula training providers,
19practicing doulas, and home visiting experts, along with State
20agencies implementing perinatal doula services and relevant
21bodies under the Illinois Early Learning Council. This body of
22experts shall inform the Department on the credentials
23necessary for perinatal doula and home visiting services to be
24eligible for Medicaid reimbursement and the rate of
25reimbursement for home visiting and perinatal doula services
26in the prenatal, labor and delivery, and postpartum periods.

 

 

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1Every 2 years, the Department shall assess the rates of
2reimbursement for perinatal doula and home visiting services
3and adjust rates accordingly.
4    (d) The Department shall seek such State plan amendments
5or waivers as may be necessary to implement this Section and
6shall secure federal financial participation for expenditures
7made by the Department in accordance with this Section.
8(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
 
9    Section 99. Effective date. This Act takes effect January
101, 2026, except that this Section and the changes to Section
115-18.5 of the Illinois Public Aid Code take effect January 1,
122025.".