Full Text of HB5142 103rd General Assembly
HB5142ham003 103RD GENERAL ASSEMBLY | Rep. Robyn Gabel Filed: 4/8/2024 | | 10300HB5142ham003 | | LRB103 38742 RPS 71976 a |
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| 1 | | AMENDMENT TO HOUSE BILL 5142
| 2 | | AMENDMENT NO. ______. Amend House Bill 5142, AS AMENDED, | 3 | | by replacing everything after the enacting clause with the | 4 | | following: | 5 | | "Section 5. The Illinois Insurance Code is amended by | 6 | | changing Sections 356z.4a and 356z.40 as follows: | 7 | | (215 ILCS 5/356z.4a) | 8 | | Sec. 356z.4a. Coverage for abortion. | 9 | | (a) Except as otherwise provided in this Section, no | 10 | | individual or group policy of accident and health insurance | 11 | | that provides pregnancy-related benefits may be issued, | 12 | | amended, delivered, or renewed in this State after the | 13 | | effective date of this amendatory Act of the 101st General | 14 | | Assembly unless the policy provides a covered person with | 15 | | coverage for abortion care. Regardless of whether the policy | 16 | | otherwise provides prescription drug benefits, abortion care |
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| 1 | | coverage must include medications that are obtained through a | 2 | | prescription and used to terminate a pregnancy, regardless of | 3 | | whether there is proof of a pregnancy. | 4 | | (b) Coverage for abortion care may not impose any | 5 | | deductible, coinsurance, waiting period, or other cost-sharing | 6 | | limitation that is greater than that required for other | 7 | | pregnancy-related benefits covered by the policy . This | 8 | | subsection does not apply to the extent that such coverage | 9 | | would disqualify a high-deductible health plan from | 10 | | eligibility for a health savings account pursuant to Section | 11 | | 223 of the Internal Revenue Code. | 12 | | (c) Except as otherwise authorized under this Section, a | 13 | | policy shall not impose any restrictions or delays on the | 14 | | coverage required under this Section. | 15 | | (d) This Section does not, pursuant to 42 U.S.C. | 16 | | 18054(a)(6), apply to a multistate plan that does not provide | 17 | | coverage for abortion. | 18 | | (e) If the Department concludes that enforcement of this | 19 | | Section may adversely affect the allocation of federal funds | 20 | | to this State, the Department may grant an exemption to the | 21 | | requirements, but only to the minimum extent necessary to | 22 | | ensure the continued receipt of federal funds. | 23 | | (Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.) | 24 | | (215 ILCS 5/356z.40) | 25 | | Sec. 356z.40. Pregnancy and postpartum coverage. |
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| 1 | | (a) An individual or group policy of accident and health | 2 | | insurance or managed care plan amended, delivered, issued, or | 3 | | renewed on or after October 8, 2021 ( the effective date of | 4 | | Public Act 102-665) this amendatory Act of the 102nd General | 5 | | Assembly shall provide coverage for pregnancy , postpartum, and | 6 | | newborn care in accordance with 42 U.S.C. 18022(b) regarding | 7 | | essential health benefits. For policies amended, delivered, | 8 | | issued, or renewed on or after January 1, 2026, this | 9 | | subsection also applies to coverage for postpartum care. | 10 | | (b) Benefits under this Section shall be as follows: | 11 | | (1) An individual who has been identified as | 12 | | experiencing a high-risk pregnancy by the individual's | 13 | | treating provider shall have access to clinically | 14 | | appropriate case management programs. As used in this | 15 | | subsection, "case management" means a mechanism to | 16 | | coordinate and assure continuity of services, including, | 17 | | but not limited to, health services, social services, and | 18 | | educational services necessary for the individual. "Case | 19 | | management" involves individualized assessment of needs, | 20 | | planning of services, referral, monitoring, and advocacy | 21 | | to assist an individual in gaining access to appropriate | 22 | | services and closure when services are no longer required. | 23 | | "Case management" is an active and collaborative process | 24 | | involving a single qualified case manager, the individual, | 25 | | the individual's family, the providers, and the community. | 26 | | This includes close coordination and involvement with all |
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| 1 | | service providers in the management plan for that | 2 | | individual or family, including assuring that the | 3 | | individual receives the services. As used in this | 4 | | subsection, "high-risk pregnancy" means a pregnancy in | 5 | | which the pregnant or postpartum individual or baby is at | 6 | | an increased risk for poor health or complications during | 7 | | pregnancy or childbirth, including, but not limited to, | 8 | | hypertension disorders, gestational diabetes, and | 9 | | hemorrhage. | 10 | | (2) An individual shall have access to medically | 11 | | necessary treatment of a mental, emotional, nervous, or | 12 | | substance use disorder or condition consistent with the | 13 | | requirements set forth in this Section and in Sections | 14 | | 370c and 370c.1 of this Code. | 15 | | (3) The benefits provided for inpatient and outpatient | 16 | | services for the treatment of a mental, emotional, | 17 | | nervous, or substance use disorder or condition related to | 18 | | pregnancy or postpartum complications shall be provided if | 19 | | determined to be medically necessary, consistent with the | 20 | | requirements of Sections 370c and 370c.1 of this Code. The | 21 | | facility or provider shall notify the insurer of both the | 22 | | admission and the initial treatment plan within 48 hours | 23 | | after admission or initiation of treatment. Nothing in | 24 | | this paragraph shall prevent an insurer from applying | 25 | | concurrent and post-service utilization review of health | 26 | | care services, including review of medical necessity, case |
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| 1 | | management, experimental and investigational treatments, | 2 | | managed care provisions, and other terms and conditions of | 3 | | the insurance policy. | 4 | | (4) The benefits for the first 48 hours of initiation | 5 | | of services for an inpatient admission, detoxification or | 6 | | withdrawal management program, or partial hospitalization | 7 | | admission for the treatment of a mental, emotional, | 8 | | nervous, or substance use disorder or condition related to | 9 | | pregnancy or postpartum complications shall be provided | 10 | | without post-service or concurrent review of medical | 11 | | necessity, as the medical necessity for the first 48 hours | 12 | | of such services shall be determined solely by the covered | 13 | | pregnant or postpartum individual's provider. Nothing in | 14 | | this paragraph shall prevent an insurer from applying | 15 | | concurrent and post-service utilization review, including | 16 | | the review of medical necessity, case management, | 17 | | experimental and investigational treatments, managed care | 18 | | provisions, and other terms and conditions of the | 19 | | insurance policy, of any inpatient admission, | 20 | | detoxification or withdrawal management program admission, | 21 | | or partial hospitalization admission services for the | 22 | | treatment of a mental, emotional, nervous, or substance | 23 | | use disorder or condition related to pregnancy or | 24 | | postpartum complications received 48 hours after the | 25 | | initiation of such services. If an insurer determines that | 26 | | the services are no longer medically necessary, then the |
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| 1 | | covered person shall have the right to external review | 2 | | pursuant to the requirements of the Health Carrier | 3 | | External Review Act. | 4 | | (5) If an insurer determines that continued inpatient | 5 | | care, detoxification or withdrawal management, partial | 6 | | hospitalization, intensive outpatient treatment, or | 7 | | outpatient treatment in a facility is no longer medically | 8 | | necessary, the insurer shall, within 24 hours, provide | 9 | | written notice to the covered pregnant or postpartum | 10 | | individual and the covered pregnant or postpartum | 11 | | individual's provider of its decision and the right to | 12 | | file an expedited internal appeal of the determination. | 13 | | The insurer shall review and make a determination with | 14 | | respect to the internal appeal within 24 hours and | 15 | | communicate such determination to the covered pregnant or | 16 | | postpartum individual and the covered pregnant or | 17 | | postpartum individual's provider. If the determination is | 18 | | to uphold the denial, the covered pregnant or postpartum | 19 | | individual and the covered pregnant or postpartum | 20 | | individual's provider have the right to file an expedited | 21 | | external appeal. An independent utilization review | 22 | | organization shall make a determination within 72 hours. | 23 | | If the insurer's determination is upheld and it is | 24 | | determined that continued inpatient care, detoxification | 25 | | or withdrawal management, partial hospitalization, | 26 | | intensive outpatient treatment, or outpatient treatment is |
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| 1 | | not medically necessary, the insurer shall remain | 2 | | responsible for providing benefits for the inpatient care, | 3 | | detoxification or withdrawal management, partial | 4 | | hospitalization, intensive outpatient treatment, or | 5 | | outpatient treatment through the day following the date | 6 | | the determination is made, and the covered pregnant or | 7 | | postpartum individual shall only be responsible for any | 8 | | applicable copayment, deductible, and coinsurance for the | 9 | | stay through that date as applicable under the policy. The | 10 | | covered pregnant or postpartum individual shall not be | 11 | | discharged or released from the inpatient facility, | 12 | | detoxification or withdrawal management, partial | 13 | | hospitalization, intensive outpatient treatment, or | 14 | | outpatient treatment until all internal appeals and | 15 | | independent utilization review organization appeals are | 16 | | exhausted. A decision to reverse an adverse determination | 17 | | shall comply with the Health Carrier External Review Act. | 18 | | (6) Except as otherwise stated in this subsection (b) | 19 | | and subsection (c) , the benefits and cost-sharing shall be | 20 | | provided to the same extent as for any other medical | 21 | | condition covered under the policy. | 22 | | (7) The benefits required by paragraphs (2) and (6) of | 23 | | this subsection (b) are to be provided to all covered | 24 | | pregnant or postpartum individuals with a diagnosis of a | 25 | | mental, emotional, nervous, or substance use disorder or | 26 | | condition. The presence of additional related or unrelated |
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| 1 | | diagnoses shall not be a basis to reduce or deny the | 2 | | benefits required by this subsection (b). | 3 | | (8) Insurers shall cover all services for pregnancy, | 4 | | postpartum, and newborn care that are rendered by | 5 | | perinatal doulas or licensed certified professional | 6 | | midwives, including home births, home visits, and support | 7 | | during labor, abortion, or miscarriage. Coverage shall | 8 | | include the necessary equipment and medical supplies for a | 9 | | home birth. For home visits by a perinatal doula, not | 10 | | counting any home birth, the policy may limit coverage to | 11 | | 16 visits before and 16 visits after a birth, miscarriage, | 12 | | or abortion. As used in this paragraph (8), "perinatal | 13 | | doula" has the meaning given in subsection (a) of Section | 14 | | 5-18.5 of the Illinois Public Aid Code. | 15 | | (9) Coverage for pregnancy, postpartum, and newborn | 16 | | care shall include home visits by lactation consultants | 17 | | and the purchase of breast pumps and breast pump supplies, | 18 | | including such breast pumps, breast pump supplies, | 19 | | breastfeeding supplies, and feeding aides as recommended | 20 | | by the lactation consultant. As used in this paragraph | 21 | | (9), "lactation consultant" means either an International | 22 | | Board-Certified Lactation Consultant or a certified | 23 | | lactation counselor as defined in subsection (a) of | 24 | | Section 5-18.10 of the Illinois Public Aid Code. | 25 | | (10) Coverage for postpartum services shall apply for | 26 | | all covered services rendered within the first 12 months |
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| 1 | | after the end of pregnancy, subject to any policy | 2 | | limitation on home visits by a perinatal doula allowed | 3 | | under paragraph (8) of this subsection (b). Nothing in | 4 | | this paragraph (10) shall be construed to require a policy | 5 | | to cover services for an individual who is no longer | 6 | | insured or enrolled under the policy. If an individual | 7 | | becomes insured or enrolled under a new policy, the new | 8 | | policy shall cover the individual consistent with the time | 9 | | period and limitations allowed under this paragraph (10). | 10 | | This paragraph (10) is subject to the requirements of | 11 | | Section 25 of the Managed Care Reform and Patient Rights | 12 | | Act, Section 20 of the Network Adequacy and Transparency | 13 | | Act, and 42 U.S.C. 300gg-113. | 14 | | (c) All coverage required under subsection (b) shall be | 15 | | provided without cost-sharing, except that, for mental health | 16 | | services, the cost-sharing prohibition does not apply to | 17 | | inpatient or residential services, and, for substance use | 18 | | disorder services, the cost-sharing prohibition applies only | 19 | | to levels of treatment below and not including Level 3.1 | 20 | | (Clinically Managed Low-Intensity Residential), as established | 21 | | by the American Society for Addiction Medicine. This | 22 | | subsection does not apply to the extent such coverage would | 23 | | disqualify a high-deductible health plan from eligibility for | 24 | | a health savings account pursuant to Section 223 of the | 25 | | Internal Revenue Code. | 26 | | (Source: P.A. 102-665, eff. 10-8-21.) |
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| 1 | | Section 10. The Illinois Public Aid Code is amended by | 2 | | changing Sections 5-16.7 and 5-18.5 as follows: | 3 | | (305 ILCS 5/5-16.7) | 4 | | Sec. 5-16.7. Post-parturition care. The medical assistance | 5 | | program shall provide the post-parturition care benefits | 6 | | required to be covered by a policy of accident and health | 7 | | insurance under Section 356s of the Illinois Insurance Code. | 8 | | On and after July 1, 2012, the Department shall reduce any | 9 | | rate of reimbursement for services or other payments or alter | 10 | | any methodologies authorized by this Code to reduce any rate | 11 | | of reimbursement for services or other payments in accordance | 12 | | with Section 5-5e. | 13 | | (Source: P.A. 97-689, eff. 6-14-12.) | 14 | | (305 ILCS 5/5-18.5) | 15 | | Sec. 5-18.5. Perinatal doula and evidence-based home | 16 | | visiting services. | 17 | | (a) As used in this Section: | 18 | | "Home visiting" means a voluntary, evidence-based strategy | 19 | | used to support pregnant people, infants, and young children | 20 | | and their caregivers to promote infant, child, and maternal | 21 | | health, to foster educational development and school | 22 | | readiness, and to help prevent child abuse and neglect. Home | 23 | | visitors are trained professionals whose visits and activities |
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| 1 | | focus on promoting strong parent-child attachment to foster | 2 | | healthy child development. | 3 | | "Perinatal doula" means a trained provider who provides | 4 | | regular, voluntary physical, emotional, and educational | 5 | | support, but not medical or midwife care, to pregnant and | 6 | | birthing persons before, during, and after childbirth, | 7 | | otherwise known as the perinatal period. | 8 | | "Perinatal doula training" means any doula training that | 9 | | focuses on providing support throughout the prenatal, labor | 10 | | and delivery, or postpartum period, and reflects the type of | 11 | | doula care that the doula seeks to provide. | 12 | | (b) Notwithstanding any other provision of this Article, | 13 | | perinatal doula services and evidence-based home visiting | 14 | | services shall be covered under the medical assistance | 15 | | program, subject to appropriation, for persons who are | 16 | | otherwise eligible for medical assistance under this Article. | 17 | | Perinatal doula services include regular visits beginning in | 18 | | the prenatal period and continuing into the postnatal period, | 19 | | inclusive of continuous support during labor and delivery, | 20 | | that support healthy pregnancies and positive birth outcomes. | 21 | | Perinatal doula services may be embedded in an existing | 22 | | program, such as evidence-based home visiting. Perinatal doula | 23 | | services provided during the prenatal period may be provided | 24 | | weekly, services provided during the labor and delivery period | 25 | | may be provided for the entire duration of labor and the time | 26 | | immediately following birth, and services provided during the |
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| 1 | | postpartum period may be provided up to 12 months postpartum. | 2 | | (b-5) Notwithstanding any other provision of this Article, | 3 | | beginning January 1, 2025 2023 , licensed certified | 4 | | professional midwife services shall be covered under the | 5 | | medical assistance program, subject to appropriation, for | 6 | | persons who are otherwise eligible for medical assistance | 7 | | under this Article. The Department shall consult with midwives | 8 | | on reimbursement rates for midwifery services. | 9 | | (c) The Department of Healthcare and Family Services shall | 10 | | adopt rules to administer this Section. In this rulemaking, | 11 | | the Department shall consider the expertise of and consult | 12 | | with doula program experts, doula training providers, | 13 | | practicing doulas, and home visiting experts, along with State | 14 | | agencies implementing perinatal doula services and relevant | 15 | | bodies under the Illinois Early Learning Council. This body of | 16 | | experts shall inform the Department on the credentials | 17 | | necessary for perinatal doula and home visiting services to be | 18 | | eligible for Medicaid reimbursement and the rate of | 19 | | reimbursement for home visiting and perinatal doula services | 20 | | in the prenatal, labor and delivery, and postpartum periods. | 21 | | Every 2 years, the Department shall assess the rates of | 22 | | reimbursement for perinatal doula and home visiting services | 23 | | and adjust rates accordingly. | 24 | | (d) The Department shall seek such State plan amendments | 25 | | or waivers as may be necessary to implement this Section and | 26 | | shall secure federal financial participation for expenditures |
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| 1 | | made by the Department in accordance with this Section. | 2 | | (Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.) | 3 | | Section 99. Effective date. This Act takes effect January | 4 | | 1, 2026, except that this Section and the changes to Section | 5 | | 5-18.5 of the Illinois Public Aid Code take effect January 1, | 6 | | 2025.". |
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