Sen. Lakesia Collins

Filed: 3/1/2024





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2    AMENDMENT NO. ______. Amend Senate Bill 3665 by replacing
3everything after the enacting clause with the following:
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 103rd General Assembly this amendatory Act of the 102nd
12General Assembly shall provide coverage for pregnancy,
13postpartum, and newborn care in accordance with 42 U.S.C.
1418022(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
8provided without cost sharing. This subsection does not apply
9to the extent such coverage would disqualify a high-deductible
10health plan from eligibility for a health savings account
11pursuant 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
14changing 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
17program shall provide the post-parturition care benefits
18required to be covered by a policy of accident and health
19insurance under Section 356s of the Illinois Insurance Code.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate
23of reimbursement for services or other payments in accordance
24with 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
4visiting services.
5    (a) As used in this Section:
6    "Home visiting" means a voluntary, evidence-based strategy
7used to support pregnant people, infants, and young children
8and their caregivers to promote infant, child, and maternal
9health, to foster educational development and school
10readiness, and to help prevent child abuse and neglect. Home
11visitors are trained professionals whose visits and activities
12focus on promoting strong parent-child attachment to foster
13healthy child development.
14    "Perinatal doula" means a trained provider who provides
15regular, voluntary physical, emotional, and educational
16support, but not medical or midwife care, to pregnant and
17birthing persons before, during, and after childbirth,
18otherwise known as the perinatal period.
19    "Perinatal doula training" means any doula training that
20focuses on providing support throughout the prenatal, labor
21and delivery, or postpartum period, and reflects the type of
22doula care that the doula seeks to provide.
23    (b) Notwithstanding any other provision of this Article,
24perinatal doula services and evidence-based home visiting
25services shall be covered under the medical assistance



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



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1bodies under the Illinois Early Learning Council. This body of
2experts shall inform the Department on the credentials
3necessary for perinatal doula and home visiting services to be
4eligible for Medicaid reimbursement and the rate of
5reimbursement for home visiting and perinatal doula services
6in the prenatal, labor and delivery, and postpartum periods.
7Every 2 years, the Department shall assess the rates of
8reimbursement for perinatal doula and home visiting services
9and adjust rates accordingly.
10    (d) The Department shall seek such State plan amendments
11or waivers as may be necessary to implement this Section and
12shall secure federal financial participation for expenditures
13made 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
161, 2026, except that this Section and the changes to Section
175-18.5 of the Illinois Public Aid Code take effect January 1,