Public Act 103-0720
 
HB5142 EnrolledLRB103 38742 RPS 68879 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 Sections 356z.4a and 356z.40 as follows:
 
    (215 ILCS 5/356z.4a)
    Sec. 356z.4a. Coverage for abortion.
    (a) Except as otherwise provided in this Section, no
individual or group policy of accident and health insurance
that provides pregnancy-related benefits may be issued,
amended, delivered, or renewed in this State after the
effective date of this amendatory Act of the 101st General
Assembly unless the policy provides a covered person with
coverage for abortion care. Regardless of whether the policy
otherwise provides prescription drug benefits, abortion care
coverage must include medications that are obtained through a
prescription and used to terminate a pregnancy, regardless of
whether there is proof of a pregnancy.
    (b) Coverage for abortion care may not impose any
deductible, coinsurance, waiting period, or other cost-sharing
limitation that is greater than that required for other
pregnancy-related benefits covered by the policy. This
subsection does not apply to the extent that such coverage
would disqualify a high-deductible health plan from
eligibility for a health savings account pursuant to Section
223 of the Internal Revenue Code.
    (c) Except as otherwise authorized under this Section, a
policy shall not impose any restrictions or delays on the
coverage required under this Section.
    (d) This Section does not, pursuant to 42 U.S.C.
18054(a)(6), apply to a multistate plan that does not provide
coverage for abortion.
    (e) If the Department concludes that enforcement of this
Section may adversely affect the allocation of federal funds
to this State, the Department may grant an exemption to the
requirements, but only to the minimum extent necessary to
ensure the continued receipt of federal funds.
(Source: P.A. 101-13, eff. 6-12-19; 102-1117, eff. 1-13-23.)
 
    (215 ILCS 5/356z.40)
    Sec. 356z.40. Pregnancy and postpartum coverage.
    (a) An individual or group policy of accident and health
insurance or managed care plan amended, delivered, issued, or
renewed on or after October 8, 2021 (the effective date of
Public Act 102-665) this amendatory Act of the 102nd General
Assembly shall provide coverage for pregnancy and newborn care
in accordance with 42 U.S.C. 18022(b) regarding essential
health benefits. For policies amended, delivered, issued, or
renewed on or after January 1, 2026, this subsection also
applies to coverage for postpartum care.
    (b) Benefits under this Section shall be as follows:
        (1) An individual who has been identified as
    experiencing a high-risk pregnancy by the individual's
    treating provider shall have access to clinically
    appropriate case management programs. As used in this
    subsection, "case management" means a mechanism to
    coordinate and assure continuity of services, including,
    but not limited to, health services, social services, and
    educational services necessary for the individual. "Case
    management" involves individualized assessment of needs,
    planning of services, referral, monitoring, and advocacy
    to assist an individual in gaining access to appropriate
    services and closure when services are no longer required.
    "Case management" is an active and collaborative process
    involving a single qualified case manager, the individual,
    the individual's family, the providers, and the community.
    This includes close coordination and involvement with all
    service providers in the management plan for that
    individual or family, including assuring that the
    individual receives the services. As used in this
    subsection, "high-risk pregnancy" means a pregnancy in
    which the pregnant or postpartum individual or baby is at
    an increased risk for poor health or complications during
    pregnancy or childbirth, including, but not limited to,
    hypertension disorders, gestational diabetes, and
    hemorrhage.
        (2) An individual shall have access to medically
    necessary treatment of a mental, emotional, nervous, or
    substance use disorder or condition consistent with the
    requirements set forth in this Section and in Sections
    370c and 370c.1 of this Code.
        (3) The benefits provided for inpatient and outpatient
    services for the treatment of a mental, emotional,
    nervous, or substance use disorder or condition related to
    pregnancy or postpartum complications shall be provided if
    determined to be medically necessary, consistent with the
    requirements of Sections 370c and 370c.1 of this Code. The
    facility or provider shall notify the insurer of both the
    admission and the initial treatment plan within 48 hours
    after admission or initiation of treatment. Nothing in
    this paragraph shall prevent an insurer from applying
    concurrent and post-service utilization review of health
    care services, including review of medical necessity, case
    management, experimental and investigational treatments,
    managed care provisions, and other terms and conditions of
    the insurance policy.
        (4) The benefits for the first 48 hours of initiation
    of services for an inpatient admission, detoxification or
    withdrawal management program, or partial hospitalization
    admission for the treatment of a mental, emotional,
    nervous, or substance use disorder or condition related to
    pregnancy or postpartum complications shall be provided
    without post-service or concurrent review of medical
    necessity, as the medical necessity for the first 48 hours
    of such services shall be determined solely by the covered
    pregnant or postpartum individual's provider. Nothing in
    this paragraph shall prevent an insurer from applying
    concurrent and post-service utilization review, including
    the review of medical necessity, case management,
    experimental and investigational treatments, managed care
    provisions, and other terms and conditions of the
    insurance policy, of any inpatient admission,
    detoxification or withdrawal management program admission,
    or partial hospitalization admission services for the
    treatment of a mental, emotional, nervous, or substance
    use disorder or condition related to pregnancy or
    postpartum complications received 48 hours after the
    initiation of such services. If an insurer determines that
    the services are no longer medically necessary, then the
    covered person shall have the right to external review
    pursuant to the requirements of the Health Carrier
    External Review Act.
        (5) If an insurer determines that continued inpatient
    care, detoxification or withdrawal management, partial
    hospitalization, intensive outpatient treatment, or
    outpatient treatment in a facility is no longer medically
    necessary, the insurer shall, within 24 hours, provide
    written notice to the covered pregnant or postpartum
    individual and the covered pregnant or postpartum
    individual's provider of its decision and the right to
    file an expedited internal appeal of the determination.
    The insurer shall review and make a determination with
    respect to the internal appeal within 24 hours and
    communicate such determination to the covered pregnant or
    postpartum individual and the covered pregnant or
    postpartum individual's provider. If the determination is
    to uphold the denial, the covered pregnant or postpartum
    individual and the covered pregnant or postpartum
    individual's provider have the right to file an expedited
    external appeal. An independent utilization review
    organization shall make a determination within 72 hours.
    If the insurer's determination is upheld and it is
    determined that continued inpatient care, detoxification
    or withdrawal management, partial hospitalization,
    intensive outpatient treatment, or outpatient treatment is
    not medically necessary, the insurer shall remain
    responsible for providing benefits for the inpatient care,
    detoxification or withdrawal management, partial
    hospitalization, intensive outpatient treatment, or
    outpatient treatment through the day following the date
    the determination is made, and the covered pregnant or
    postpartum individual shall only be responsible for any
    applicable copayment, deductible, and coinsurance for the
    stay through that date as applicable under the policy. The
    covered pregnant or postpartum individual shall not be
    discharged or released from the inpatient facility,
    detoxification or withdrawal management, partial
    hospitalization, intensive outpatient treatment, or
    outpatient treatment until all internal appeals and
    independent utilization review organization appeals are
    exhausted. A decision to reverse an adverse determination
    shall comply with the Health Carrier External Review Act.
        (6) Except as otherwise stated in this subsection (b)
    and subsection (c), the benefits and cost-sharing shall be
    provided to the same extent as for any other medical
    condition covered under the policy.
        (7) The benefits required by paragraphs (2) and (6) of
    this subsection (b) are to be provided to all covered
    pregnant or postpartum individuals with a diagnosis of a
    mental, emotional, nervous, or substance use disorder or
    condition. The presence of additional related or unrelated
    diagnoses shall not be a basis to reduce or deny the
    benefits required by this subsection (b).
        (8) Insurers shall cover all services for pregnancy,
    postpartum, and newborn care that are rendered by
    perinatal doulas or licensed certified professional
    midwives, including home births, home visits, and support
    during labor, abortion, or miscarriage. Coverage shall
    include the necessary equipment and medical supplies for a
    home birth. For home visits by a perinatal doula, not
    counting any home birth, the policy may limit coverage to
    16 visits before and 16 visits after a birth, miscarriage,
    or abortion, provided that the policy shall not be
    required to cover more than $8,000 for doula visits for
    each pregnancy and subsequent postpartum period. As used
    in this paragraph (8), "perinatal doula" has the meaning
    given in subsection (a) of Section 5-18.5 of the Illinois
    Public Aid Code.
        (9) Coverage for pregnancy, postpartum, and newborn
    care shall include home visits by lactation consultants
    and the purchase of breast pumps and breast pump supplies,
    including such breast pumps, breast pump supplies,
    breastfeeding supplies, and feeding aids as recommended by
    the lactation consultant. As used in this paragraph (9),
    "lactation consultant" means an International
    Board-Certified Lactation Consultant, a certified
    lactation specialist with a certification from Lactation
    Education Consultants, or a certified lactation counselor
    as defined in subsection (a) of Section 5-18.10 of the
    Illinois Public Aid Code.
        (10) Coverage for postpartum services shall apply for
    all covered services rendered within the first 12 months
    after the end of pregnancy, subject to any policy
    limitation on home visits by a perinatal doula allowed
    under paragraph (8) of this subsection (b). Nothing in
    this paragraph (10) shall be construed to require a policy
    to cover services for an individual who is no longer
    insured or enrolled under the policy. If an individual
    becomes insured or enrolled under a new policy, the new
    policy shall cover the individual consistent with the time
    period and limitations allowed under this paragraph (10).
    This paragraph (10) is subject to the requirements of
    Section 25 of the Managed Care Reform and Patient Rights
    Act, Section 20 of the Network Adequacy and Transparency
    Act, and 42 U.S.C. 300gg-113.
    (c) All coverage described in subsection (b), other than
health care services for home births, shall be provided
without cost-sharing, except that, for mental health services,
the cost-sharing prohibition does not apply to inpatient or
residential services, and, for substance use disorder
services, the cost-sharing prohibition applies only to levels
of treatment below and not including Level 3.1 (Clinically
Managed Low-Intensity Residential), as established by the
American Society for Addiction Medicine. This subsection does
not apply to the extent such coverage would disqualify a
high-deductible health plan from eligibility for a health
savings account pursuant to Section 223 of the Internal
Revenue Code.
(Source: P.A. 102-665, eff. 10-8-21.)
 
    Section 10. The Illinois Public Aid Code is amended by
changing Sections 5-16.7 and 5-18.5 as follows:
 
    (305 ILCS 5/5-16.7)
    Sec. 5-16.7. Post-parturition care. The medical assistance
program shall provide the post-parturition care benefits
required to be covered by a policy of accident and health
insurance under Section 356s 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.
(Source: P.A. 97-689, eff. 6-14-12.)
 
    (305 ILCS 5/5-18.5)
    Sec. 5-18.5. Perinatal doula and evidence-based home
visiting services.
    (a) As used in this Section:
    "Home visiting" means a voluntary, evidence-based strategy
used to support pregnant people, infants, and young children
and their caregivers to promote infant, child, and maternal
health, to foster educational development and school
readiness, and to help prevent child abuse and neglect. Home
visitors are trained professionals whose visits and activities
focus on promoting strong parent-child attachment to foster
healthy child development.
    "Perinatal doula" means a trained provider who provides
regular, voluntary physical, emotional, and educational
support, but not medical or midwife care, to pregnant and
birthing persons before, during, and after childbirth,
otherwise known as the perinatal period.
    "Perinatal doula training" means any doula training that
focuses on providing support throughout the prenatal, labor
and delivery, or postpartum period, and reflects the type of
doula care that the doula seeks to provide.
    (b) Notwithstanding any other provision of this Article,
perinatal doula services and evidence-based home visiting
services shall be covered under the medical assistance
program, subject to appropriation, for persons who are
otherwise eligible for medical assistance under this Article.
Perinatal doula services include regular visits beginning in
the prenatal period and continuing into the postnatal period,
inclusive of continuous support during labor and delivery,
that support healthy pregnancies and positive birth outcomes.
Perinatal doula services may be embedded in an existing
program, such as evidence-based home visiting. Perinatal doula
services provided during the prenatal period may be provided
weekly, services provided during the labor and delivery period
may be provided for the entire duration of labor and the time
immediately following birth, and services provided during the
postpartum period may be provided up to 12 months postpartum.
    (b-5) Notwithstanding any other provision of this Article,
beginning January 1, 2023, licensed certified professional
midwife services and, beginning January 1, 2025, certified
professional midwife services shall be covered under the
medical assistance program, subject to appropriation, for
persons who are otherwise eligible for medical assistance
under this Article. The Department shall consult with midwives
on reimbursement rates for midwifery services.
    (c) The Department of Healthcare and Family Services shall
adopt rules to administer this Section. In this rulemaking,
the Department shall consider the expertise of and consult
with doula program experts, doula training providers,
practicing doulas, and home visiting experts, along with State
agencies implementing perinatal doula services and relevant
bodies under the Illinois Early Learning Council. This body of
experts shall inform the Department on the credentials
necessary for perinatal doula and home visiting services to be
eligible for Medicaid reimbursement and the rate of
reimbursement for home visiting and perinatal doula services
in the prenatal, labor and delivery, and postpartum periods.
Every 2 years, the Department shall assess the rates of
reimbursement for perinatal doula and home visiting services
and adjust rates accordingly.
    (d) The Department shall seek such State plan amendments
or waivers as may be necessary to implement this Section and
shall secure federal financial participation for expenditures
made by the Department in accordance with this Section.
(Source: P.A. 102-4, eff. 4-27-21; 102-1037, eff. 6-2-22.)
 
    Section 99. Effective date. This Act takes effect January
1, 2026, except that this Section and the changes to Section
5-18.5 of the Illinois Public Aid Code take effect January 1,
2025.