Full Text of HB5282 103rd General Assembly
HB5282enr 103RD GENERAL ASSEMBLY | | | HB5282 Enrolled | | LRB103 38746 RPS 68883 b |
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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. |
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