HB5295eng 103RD GENERAL ASSEMBLY

HB5295 Engrossed LRB103 38679 RPS 68816 b

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by changing Section 356z.56 as follows:

(215 ILCS 5/356z.56)

Sec. 356z.56. Coverage for hormonal and non-hormonal hormone therapy to treat menopause. A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed in this State on or after January 1, 2024 shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy. This coverage applies only to coverage provided on or after January 1, 2024 and before January 1, 2026.

A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall provide coverage for medically necessary hormonal and non-hormonal therapy to treat menopausal symptoms if the therapy is recommended by a qualified health care provider who is licensed, accredited, or certified under Illinois law and the therapy has been proven safe and effective in peer-reviewed scientific studies. Coverage for therapy to treat menopausal symptoms shall include all federal Food and Drug Administration-approved modalities of hormonal and non-hormonal administration, including, but not limited to, oral, transdermal, topical, and vaginal rings.

(Source: P.A. 102-804, eff. 1-1-23; 103-154, eff. 6-30-23.)

Section 10. The Illinois Public Aid Code is amended by changing Section 5-16.8 and by adding Section 5-52 as follows:

(305 ILCS 5/5-16.8)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.56, 356z.59, 356z.60, and 356z.61, 356z.64, and 356z.67 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 102-30, eff. 1-1-22; 102-144, eff. 1-1-22; 102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-530, eff. 1-1-22; 102-642, eff. 1-1-22; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; revised 12-15-23.)

(305 ILCS 5/5-52 new)

Sec. 5-52. Coverage for hormonal therapy to treat menopause. The medical assistance program shall provide coverage for medically necessary hormone therapy treatment to treat menopause that has been induced by a hysterectomy.

Section 99. Effective date. This Act takes effect January 1, 2026.