|
| Public Act 103-0701
|
| HB5282 Enrolled | LRB103 38746 RPS 68883 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.40 as follows:
|
(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 the effective date of 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. |
(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), |
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 (i) all covered |
pregnant or postpartum individuals with a diagnosis of a |
mental, emotional, nervous, or substance use disorder or |
condition and (ii) all individuals who have experienced a |
miscarriage or stillbirth. The presence of additional |
related or unrelated diagnoses shall not be a basis to |
reduce or deny the benefits required by this subsection |
(b). |
(Source: P.A. 102-665, eff. 10-8-21.)
|
