103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB5282

 

Introduced 2/9/2024, by Rep. Anne Stava-Murray

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.40

    Amends the Illinois Insurance Code. Requires coverage of medically necessary treatment of a mental, emotional, nervous, or substance use disorder or condition for all individuals who have experienced a miscarriage or stillbirth to the same extent and cost-sharing as for any other medical condition covered under the policy. Effective January 1, 2025.


LRB103 38746 RPS 68883 b

 

 

A BILL FOR

 

HB5282LRB103 38746 RPS 68883 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 102nd General Assembly shall provide coverage for
12pregnancy and newborn care in accordance with 42 U.S.C.
1318022(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,

 

 

HB5282- 2 -LRB103 38746 RPS 68883 b

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

 

 

HB5282- 3 -LRB103 38746 RPS 68883 b

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,

 

 

HB5282- 4 -LRB103 38746 RPS 68883 b

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

 

 

HB5282- 5 -LRB103 38746 RPS 68883 b

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

 

 

HB5282- 6 -LRB103 38746 RPS 68883 b

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
141, 2025.