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Sen. Lakesia Collins
Filed: 3/1/2024
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1 | | AMENDMENT TO SENATE BILL 3665
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2 | | AMENDMENT NO. ______. Amend Senate Bill 3665 by replacing |
3 | | everything after the enacting clause with the following: |
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 103rd General Assembly this amendatory Act of the 102nd |
12 | | General Assembly shall provide coverage for pregnancy , |
13 | | postpartum, and newborn care in accordance with 42 U.S.C. |
14 | | 18022(b) regarding essential health benefits. |
15 | | (b) Benefits under this Section shall be as follows: |
16 | | (1) An individual who has been identified as |
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1 | | experiencing a high-risk pregnancy by the individual's |
2 | | treating provider shall have access to clinically |
3 | | appropriate case management programs. As used in this |
4 | | subsection, "case management" means a mechanism to |
5 | | coordinate and assure continuity of services, including, |
6 | | but not limited to, health services, social services, and |
7 | | educational services necessary for the individual. "Case |
8 | | management" involves individualized assessment of needs, |
9 | | planning of services, referral, monitoring, and advocacy |
10 | | to assist an individual in gaining access to appropriate |
11 | | services and closure when services are no longer required. |
12 | | "Case management" is an active and collaborative process |
13 | | involving a single qualified case manager, the individual, |
14 | | the individual's family, the providers, and the community. |
15 | | This includes close coordination and involvement with all |
16 | | service providers in the management plan for that |
17 | | individual or family, including assuring that the |
18 | | individual receives the services. As used in this |
19 | | subsection, "high-risk pregnancy" means a pregnancy in |
20 | | which the pregnant or postpartum individual or baby is at |
21 | | an increased risk for poor health or complications during |
22 | | pregnancy or childbirth, including, but not limited to, |
23 | | hypertension disorders, gestational diabetes, and |
24 | | hemorrhage. |
25 | | (2) An individual shall have access to medically |
26 | | necessary treatment of a mental, emotional, nervous, or |
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1 | | substance use disorder or condition consistent with the |
2 | | requirements set forth in this Section and in Sections |
3 | | 370c and 370c.1 of this Code. |
4 | | (3) The benefits provided for inpatient and outpatient |
5 | | services for the treatment of a mental, emotional, |
6 | | nervous, or substance use disorder or condition related to |
7 | | pregnancy or postpartum complications shall be provided if |
8 | | determined to be medically necessary, consistent with the |
9 | | requirements of Sections 370c and 370c.1 of this Code. The |
10 | | facility or provider shall notify the insurer of both the |
11 | | admission and the initial treatment plan within 48 hours |
12 | | after admission or initiation of treatment. Nothing in |
13 | | this paragraph shall prevent an insurer from applying |
14 | | concurrent and post-service utilization review of health |
15 | | care services, including review of medical necessity, case |
16 | | management, experimental and investigational treatments, |
17 | | managed care provisions, and other terms and conditions of |
18 | | the insurance policy. |
19 | | (4) The benefits for the first 48 hours of initiation |
20 | | of services for an inpatient admission, detoxification or |
21 | | withdrawal management program, or partial hospitalization |
22 | | admission for the treatment of a mental, emotional, |
23 | | nervous, or substance use disorder or condition related to |
24 | | pregnancy or postpartum complications shall be provided |
25 | | without post-service or concurrent review of medical |
26 | | necessity, as the medical necessity for the first 48 hours |
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1 | | of such services shall be determined solely by the covered |
2 | | pregnant or postpartum individual's provider. Nothing in |
3 | | this paragraph shall prevent an insurer from applying |
4 | | concurrent and post-service utilization review, including |
5 | | the review of medical necessity, case management, |
6 | | experimental and investigational treatments, managed care |
7 | | provisions, and other terms and conditions of the |
8 | | insurance policy, of any inpatient admission, |
9 | | detoxification or withdrawal management program admission, |
10 | | or partial hospitalization admission services for the |
11 | | treatment of a mental, emotional, nervous, or substance |
12 | | use disorder or condition related to pregnancy or |
13 | | postpartum complications received 48 hours after the |
14 | | initiation of such services. If an insurer determines that |
15 | | the services are no longer medically necessary, then the |
16 | | covered person shall have the right to external review |
17 | | pursuant to the requirements of the Health Carrier |
18 | | External Review Act. |
19 | | (5) If an insurer determines that continued inpatient |
20 | | care, detoxification or withdrawal management, partial |
21 | | hospitalization, intensive outpatient treatment, or |
22 | | outpatient treatment in a facility is no longer medically |
23 | | necessary, the insurer shall, within 24 hours, provide |
24 | | written notice to the covered pregnant or postpartum |
25 | | individual and the covered pregnant or postpartum |
26 | | individual's provider of its decision and the right to |
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1 | | file an expedited internal appeal of the determination. |
2 | | The insurer shall review and make a determination with |
3 | | respect to the internal appeal within 24 hours and |
4 | | communicate such determination to the covered pregnant or |
5 | | postpartum individual and the covered pregnant or |
6 | | postpartum individual's provider. If the determination is |
7 | | to uphold the denial, the covered pregnant or postpartum |
8 | | individual and the covered pregnant or postpartum |
9 | | individual's provider have the right to file an expedited |
10 | | external appeal. An independent utilization review |
11 | | organization shall make a determination within 72 hours. |
12 | | If the insurer's determination is upheld and it is |
13 | | determined that continued inpatient care, detoxification |
14 | | or withdrawal management, partial hospitalization, |
15 | | intensive outpatient treatment, or outpatient treatment is |
16 | | not medically necessary, the insurer shall remain |
17 | | responsible for providing benefits for the inpatient care, |
18 | | detoxification or withdrawal management, partial |
19 | | hospitalization, intensive outpatient treatment, or |
20 | | outpatient treatment through the day following the date |
21 | | the determination is made, and the covered pregnant or |
22 | | postpartum individual shall only be responsible for any |
23 | | applicable copayment, deductible, and coinsurance for the |
24 | | stay through that date as applicable under the policy. The |
25 | | covered pregnant or postpartum individual shall not be |
26 | | discharged or released from the inpatient facility, |
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1 | | detoxification or withdrawal management, partial |
2 | | hospitalization, intensive outpatient treatment, or |
3 | | outpatient treatment until all internal appeals and |
4 | | independent utilization review organization appeals are |
5 | | exhausted. A decision to reverse an adverse determination |
6 | | shall comply with the Health Carrier External Review Act. |
7 | | (6) Except as otherwise stated in this subsection (b), |
8 | | the benefits and cost-sharing shall be provided to the |
9 | | same extent as for any other medical condition covered |
10 | | under the policy. |
11 | | (7) The benefits required by paragraphs (2) and (6) of |
12 | | this subsection (b) are to be provided to all covered |
13 | | pregnant or postpartum individuals with a diagnosis of a |
14 | | mental, emotional, nervous, or substance use disorder or |
15 | | condition. The presence of additional related or unrelated |
16 | | diagnoses shall not be a basis to reduce or deny the |
17 | | benefits required by this subsection (b). |
18 | | (8) Insurers shall cover all services for pregnancy, |
19 | | postpartum, and newborn care that are rendered by |
20 | | perinatal doulas or licensed certified professional |
21 | | midwives, including home births, home visits, and support |
22 | | during labor, abortion, or miscarriage. Coverage shall |
23 | | include the necessary equipment and medical supplies for a |
24 | | home birth. |
25 | | (9) Coverage for pregnancy, postpartum, and newborn |
26 | | care shall include home visits by lactation consultants |
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1 | | and the purchase of breast pumps and breast pump supplies, |
2 | | including such breast pumps, breast pump supplies, |
3 | | breastfeeding supplies, and feeding aides as recommended |
4 | | by the lactation consultant. |
5 | | (10) Coverage for postpartum services shall apply for |
6 | | at least one year after the end of the pregnancy. |
7 | | (c) All coverage required under this Section shall be |
8 | | provided without cost sharing. This subsection does not apply |
9 | | to the extent such coverage would disqualify a high-deductible |
10 | | health plan from eligibility for a health savings account |
11 | | pursuant to Section 223 of the Internal Revenue Code. |
12 | | (Source: P.A. 102-665, eff. 10-8-21.) |
13 | | Section 10. The Illinois Public Aid Code is amended by |
14 | | changing Sections 5-16.7 and 5-18.5 as follows: |
15 | | (305 ILCS 5/5-16.7) |
16 | | Sec. 5-16.7. Post-parturition care. The medical assistance |
17 | | program shall provide the post-parturition care benefits |
18 | | required to be covered by a policy of accident and health |
19 | | insurance under Section 356s of the Illinois Insurance Code. |
20 | | On and after July 1, 2012, the Department shall reduce any |
21 | | rate of reimbursement for services or other payments or alter |
22 | | any methodologies authorized by this Code to reduce any rate |
23 | | of reimbursement for services or other payments in accordance |
24 | | with Section 5-5e. |
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1 | | (Source: P.A. 97-689, eff. 6-14-12.) |
2 | | (305 ILCS 5/5-18.5) |
3 | | Sec. 5-18.5. Perinatal doula and evidence-based home |
4 | | visiting services. |
5 | | (a) As used in this Section: |
6 | | "Home visiting" means a voluntary, evidence-based strategy |
7 | | used to support pregnant people, infants, and young children |
8 | | and their caregivers to promote infant, child, and maternal |
9 | | health, to foster educational development and school |
10 | | readiness, and to help prevent child abuse and neglect. Home |
11 | | visitors are trained professionals whose visits and activities |
12 | | focus on promoting strong parent-child attachment to foster |
13 | | healthy child development. |
14 | | "Perinatal doula" means a trained provider who provides |
15 | | regular, voluntary physical, emotional, and educational |
16 | | support, but not medical or midwife care, to pregnant and |
17 | | birthing persons before, during, and after childbirth, |
18 | | otherwise known as the perinatal period. |
19 | | "Perinatal doula training" means any doula training that |
20 | | focuses on providing support throughout the prenatal, labor |
21 | | and delivery, or postpartum period, and reflects the type of |
22 | | doula care that the doula seeks to provide. |
23 | | (b) Notwithstanding any other provision of this Article, |
24 | | perinatal doula services and evidence-based home visiting |
25 | | services shall be covered under the medical assistance |
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1 | | program, subject to appropriation, for persons who are |
2 | | otherwise eligible for medical assistance under this Article. |
3 | | Perinatal doula services include regular visits beginning in |
4 | | the prenatal period and continuing into the postnatal period, |
5 | | inclusive of continuous support during labor and delivery, |
6 | | that support healthy pregnancies and positive birth outcomes. |
7 | | Perinatal doula services may be embedded in an existing |
8 | | program, such as evidence-based home visiting. Perinatal doula |
9 | | services provided during the prenatal period may be provided |
10 | | weekly, services provided during the labor and delivery period |
11 | | may be provided for the entire duration of labor and the time |
12 | | immediately following birth, and services provided during the |
13 | | postpartum period may be provided up to 12 months postpartum. |
14 | | (b-5) Notwithstanding any other provision of this Article, |
15 | | beginning January 1, 2025 2023 , licensed certified |
16 | | professional midwife services shall be covered under the |
17 | | medical assistance program, subject to appropriation, for |
18 | | persons who are otherwise eligible for medical assistance |
19 | | under this Article. The Department shall consult with midwives |
20 | | on reimbursement rates for midwifery services. |
21 | | (c) The Department of Healthcare and Family Services shall |
22 | | adopt rules to administer this Section. In this rulemaking, |
23 | | the Department shall consider the expertise of and consult |
24 | | with doula program experts, doula training providers, |
25 | | practicing doulas, and home visiting experts, along with State |
26 | | agencies implementing perinatal doula services and relevant |
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1 | | bodies under the Illinois Early Learning Council. This body of |
2 | | experts shall inform the Department on the credentials |
3 | | necessary for perinatal doula and home visiting services to be |
4 | | eligible for Medicaid reimbursement and the rate of |
5 | | reimbursement for home visiting and perinatal doula services |
6 | | in the prenatal, labor and delivery, and postpartum periods. |
7 | | Every 2 years, the Department shall assess the rates of |
8 | | reimbursement for perinatal doula and home visiting services |
9 | | and adjust rates accordingly. |
10 | | (d) The Department shall seek such State plan amendments |
11 | | or waivers as may be necessary to implement this Section and |
12 | | shall secure federal financial participation for expenditures |
13 | | made by the Department in accordance with this Section. |
14 | | (Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.) |
15 | | Section 99. Effective date. This Act takes effect January |
16 | | 1, 2026, except that this Section and the changes to Section |
17 | | 5-18.5 of the Illinois Public Aid Code take effect January 1, |
18 | | 2025.". |