Bill Text: IL HB5142 | 2023-2024 | 103rd General Assembly | Engrossed

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Bill Title: Reinserts the provisions of the bill as amended by House Amendment No. 1 with changes. Further amends the Illinois Insurance Code. Provides that coverage for abortion care may not impose any deductible, coinsurance, waiting period, or other cost-sharing limitation, except to the extent that the coverage would disqualify a high-deductible health plan from eligibility for a health savings account (rather than 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). Defines "perinatal doula" and "lactation consultant". Provides that coverage for postpartum services shall apply for all covered services rendered within the first 12 months after the end of pregnancy (rather than the coverage shall apply for at least one year after the end of pregnancy), except that a policy is not required to cover more than $8,000 for doula visits for each pregnancy and subsequent postpartum period. Provides that all outpatient coverage, other than health care services for home births, required under a provision concerning coverage for pregnancy, postpartum, and newborn care must 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 treatment of substance use disorders, the prohibition on cost-sharing applies to the levels of treatment below and not including Level 3.1 (Clinically Managed Low-Intensity Residential) established by the American Society of Addiction Medicine. Makes other changes. Effective January 1, 2026, except that certain changes to the Illinois Public Aid Code are effective January 1, 2025.

Spectrum: Partisan Bill (Democrat 40-0)

Status: (Engrossed) 2024-04-19 - Referred to Assignments [HB5142 Detail]

Download: Illinois-2023-HB5142-Engrossed.html

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HB5142 Engrossed LRB103 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

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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

HB5142 Engrossed - 3 - LRB103 38742 RPS 68879 b
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

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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

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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

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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

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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

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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

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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

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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.

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"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,

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beginning January 1, 2025 2023, licensed 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.)

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