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1 | AN ACT concerning regulation. | ||||||
2 | Be it enacted by the People of the State of Illinois, | ||||||
3 | represented in the General Assembly: | ||||||
4 | Section 5. The Illinois Insurance Code is amended by | ||||||
5 | changing 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 | ||||||
9 | insurance or managed care plan amended, delivered, issued, or | ||||||
10 | renewed on or after the effective date of this amendatory Act | ||||||
11 | of the 102nd General Assembly shall provide coverage for | ||||||
12 | pregnancy and newborn care in accordance with 42 U.S.C. | ||||||
13 | 18022(b) regarding essential health benefits. | ||||||
14 | (b) Benefits under this Section shall be as follows: | ||||||
15 | (1) An individual who has been identified as | ||||||
16 | experiencing a high-risk pregnancy by the individual's | ||||||
17 | treating provider shall have access to clinically | ||||||
18 | appropriate case management programs. As used in this | ||||||
19 | subsection, "case management" means a mechanism to | ||||||
20 | coordinate and assure continuity of services, including, | ||||||
21 | but not limited to, health services, social services, and | ||||||
22 | educational services necessary for the individual. "Case | ||||||
23 | management" involves individualized assessment of needs, |
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1 | planning of services, referral, monitoring, and advocacy | ||||||
2 | to assist an individual in gaining access to appropriate | ||||||
3 | services and closure when services are no longer required. | ||||||
4 | "Case management" is an active and collaborative process | ||||||
5 | involving a single qualified case manager, the individual, | ||||||
6 | the individual's family, the providers, and the community. | ||||||
7 | This includes close coordination and involvement with all | ||||||
8 | service providers in the management plan for that | ||||||
9 | individual or family, including assuring that the | ||||||
10 | individual receives the services. As used in this | ||||||
11 | subsection, "high-risk pregnancy" means a pregnancy in | ||||||
12 | which the pregnant or postpartum individual or baby is at | ||||||
13 | an increased risk for poor health or complications during | ||||||
14 | pregnancy or childbirth, including, but not limited to, | ||||||
15 | hypertension disorders, gestational diabetes, and | ||||||
16 | hemorrhage. | ||||||
17 | (2) An individual shall have access to medically | ||||||
18 | necessary treatment of a mental, emotional, nervous, or | ||||||
19 | substance use disorder or condition consistent with the | ||||||
20 | requirements set forth in this Section and in Sections | ||||||
21 | 370c and 370c.1 of this Code. | ||||||
22 | (3) The benefits provided for inpatient and outpatient | ||||||
23 | services for the treatment of a mental, emotional, | ||||||
24 | nervous, or substance use disorder or condition related to | ||||||
25 | pregnancy or postpartum complications shall be provided if | ||||||
26 | determined to be medically necessary, consistent with the |
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1 | requirements of Sections 370c and 370c.1 of this Code. The | ||||||
2 | facility or provider shall notify the insurer of both the | ||||||
3 | admission and the initial treatment plan within 48 hours | ||||||
4 | after admission or initiation of treatment. Nothing in | ||||||
5 | this paragraph shall prevent an insurer from applying | ||||||
6 | concurrent and post-service utilization review of health | ||||||
7 | care services, including review of medical necessity, case | ||||||
8 | management, experimental and investigational treatments, | ||||||
9 | managed care provisions, and other terms and conditions of | ||||||
10 | the insurance policy. | ||||||
11 | (4) The benefits for the first 48 hours of initiation | ||||||
12 | of services for an inpatient admission, detoxification or | ||||||
13 | withdrawal management program, or partial hospitalization | ||||||
14 | admission for the treatment of a mental, emotional, | ||||||
15 | nervous, or substance use disorder or condition related to | ||||||
16 | pregnancy or postpartum complications shall be provided | ||||||
17 | without post-service or concurrent review of medical | ||||||
18 | necessity, as the medical necessity for the first 48 hours | ||||||
19 | of such services shall be determined solely by the covered | ||||||
20 | pregnant or postpartum individual's provider. Nothing in | ||||||
21 | this paragraph shall prevent an insurer from applying | ||||||
22 | concurrent and post-service utilization review, including | ||||||
23 | the review of medical necessity, case management, | ||||||
24 | experimental and investigational treatments, managed care | ||||||
25 | provisions, and other terms and conditions of the | ||||||
26 | insurance policy, of any inpatient admission, |
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1 | detoxification or withdrawal management program admission, | ||||||
2 | or partial hospitalization admission services for the | ||||||
3 | treatment of a mental, emotional, nervous, or substance | ||||||
4 | use disorder or condition related to pregnancy or | ||||||
5 | postpartum complications received 48 hours after the | ||||||
6 | initiation of such services. If an insurer determines that | ||||||
7 | the services are no longer medically necessary, then the | ||||||
8 | covered person shall have the right to external review | ||||||
9 | pursuant to the requirements of the Health Carrier | ||||||
10 | External Review Act. | ||||||
11 | (5) If an insurer determines that continued inpatient | ||||||
12 | care, detoxification or withdrawal management, partial | ||||||
13 | hospitalization, intensive outpatient treatment, or | ||||||
14 | outpatient treatment in a facility is no longer medically | ||||||
15 | necessary, the insurer shall, within 24 hours, provide | ||||||
16 | written notice to the covered pregnant or postpartum | ||||||
17 | individual and the covered pregnant or postpartum | ||||||
18 | individual's provider of its decision and the right to | ||||||
19 | file an expedited internal appeal of the determination. | ||||||
20 | The insurer shall review and make a determination with | ||||||
21 | respect to the internal appeal within 24 hours and | ||||||
22 | communicate such determination to the covered pregnant or | ||||||
23 | postpartum individual and the covered pregnant or | ||||||
24 | postpartum individual's provider. If the determination is | ||||||
25 | to uphold the denial, the covered pregnant or postpartum | ||||||
26 | individual and the covered pregnant or postpartum |
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1 | individual's provider have the right to file an expedited | ||||||
2 | external appeal. An independent utilization review | ||||||
3 | organization shall make a determination within 72 hours. | ||||||
4 | If the insurer's determination is upheld and it is | ||||||
5 | determined that continued inpatient care, detoxification | ||||||
6 | or withdrawal management, partial hospitalization, | ||||||
7 | intensive outpatient treatment, or outpatient treatment is | ||||||
8 | not medically necessary, the insurer shall remain | ||||||
9 | responsible for providing benefits for the inpatient care, | ||||||
10 | detoxification or withdrawal management, partial | ||||||
11 | hospitalization, intensive outpatient treatment, or | ||||||
12 | outpatient treatment through the day following the date | ||||||
13 | the determination is made, and the covered pregnant or | ||||||
14 | postpartum individual shall only be responsible for any | ||||||
15 | applicable copayment, deductible, and coinsurance for the | ||||||
16 | stay through that date as applicable under the policy. The | ||||||
17 | covered pregnant or postpartum individual shall not be | ||||||
18 | discharged or released from the inpatient facility, | ||||||
19 | detoxification or withdrawal management, partial | ||||||
20 | hospitalization, intensive outpatient treatment, or | ||||||
21 | outpatient treatment until all internal appeals and | ||||||
22 | independent utilization review organization appeals are | ||||||
23 | exhausted. A decision to reverse an adverse determination | ||||||
24 | shall comply with the Health Carrier External Review Act. | ||||||
25 | (6) Except as otherwise stated in this subsection (b), | ||||||
26 | the benefits and cost-sharing shall be provided to the |
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1 | same extent as for any other medical condition covered | ||||||
2 | under the policy. | ||||||
3 | (7) The benefits required by paragraphs (2) and (6) of | ||||||
4 | this subsection (b) are to be provided to (i) all covered | ||||||
5 | pregnant or postpartum individuals with a diagnosis of a | ||||||
6 | mental, emotional, nervous, or substance use disorder or | ||||||
7 | condition and (ii) all individuals who have experienced a | ||||||
8 | miscarriage or stillbirth . The presence of additional | ||||||
9 | related or unrelated diagnoses shall not be a basis to | ||||||
10 | reduce or deny the benefits required by this subsection | ||||||
11 | (b). | ||||||
12 | (Source: P.A. 102-665, eff. 10-8-21.) | ||||||
13 | Section 99. Effective date. This Act takes effect January | ||||||
14 | 1, 2026. |