HB5282ham001 103RD GENERAL ASSEMBLY

Rep. Anne Stava-Murray

Filed: 4/3/2024

 

 


 

 


 
10300HB5282ham001LRB103 38746 RPS 71778 a

1
AMENDMENT TO HOUSE BILL 5282

2    AMENDMENT NO. ______. Amend House Bill 5282 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.40 as follows:
 
6    (215 ILCS 5/356z.40)
7    Sec. 356z.40. Pregnancy and postpartum coverage.
8    (a) An individual or group policy of accident and health
9insurance or managed care plan amended, delivered, issued, or
10renewed on or after the effective date of this amendatory Act
11of the 102nd General Assembly shall provide coverage for
12pregnancy and newborn care in accordance with 42 U.S.C.
1318022(b) regarding essential health benefits.
14    (b) Benefits under this Section shall be as follows:
15        (1) An individual who has been identified as
16    experiencing a high-risk pregnancy by the individual's

 

 

10300HB5282ham001- 2 -LRB103 38746 RPS 71778 a

1    treating provider shall have access to clinically
2    appropriate case management programs. As used in this
3    subsection, "case management" means a mechanism to
4    coordinate and assure continuity of services, including,
5    but not limited to, health services, social services, and
6    educational services necessary for the individual. "Case
7    management" involves individualized assessment of needs,
8    planning of services, referral, monitoring, and advocacy
9    to assist an individual in gaining access to appropriate
10    services and closure when services are no longer required.
11    "Case management" is an active and collaborative process
12    involving a single qualified case manager, the individual,
13    the individual's family, the providers, and the community.
14    This includes close coordination and involvement with all
15    service providers in the management plan for that
16    individual or family, including assuring that the
17    individual receives the services. As used in this
18    subsection, "high-risk pregnancy" means a pregnancy in
19    which the pregnant or postpartum individual or baby is at
20    an increased risk for poor health or complications during
21    pregnancy or childbirth, including, but not limited to,
22    hypertension disorders, gestational diabetes, and
23    hemorrhage.
24        (2) An individual shall have access to medically
25    necessary treatment of a mental, emotional, nervous, or
26    substance use disorder or condition consistent with the

 

 

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1    requirements set forth in this Section and in Sections
2    370c and 370c.1 of this Code.
3        (3) The benefits provided for inpatient and outpatient
4    services for the treatment of a mental, emotional,
5    nervous, or substance use disorder or condition related to
6    pregnancy or postpartum complications shall be provided if
7    determined to be medically necessary, consistent with the
8    requirements of Sections 370c and 370c.1 of this Code. The
9    facility or provider shall notify the insurer of both the
10    admission and the initial treatment plan within 48 hours
11    after admission or initiation of treatment. Nothing in
12    this paragraph shall prevent an insurer from applying
13    concurrent and post-service utilization review of health
14    care services, including review of medical necessity, case
15    management, experimental and investigational treatments,
16    managed care provisions, and other terms and conditions of
17    the insurance policy.
18        (4) The benefits for the first 48 hours of initiation
19    of services for an inpatient admission, detoxification or
20    withdrawal management program, or partial hospitalization
21    admission for the treatment of a mental, emotional,
22    nervous, or substance use disorder or condition related to
23    pregnancy or postpartum complications shall be provided
24    without post-service or concurrent review of medical
25    necessity, as the medical necessity for the first 48 hours
26    of such services shall be determined solely by the covered

 

 

10300HB5282ham001- 4 -LRB103 38746 RPS 71778 a

1    pregnant or postpartum individual's provider. Nothing in
2    this paragraph shall prevent an insurer from applying
3    concurrent and post-service utilization review, including
4    the review of medical necessity, case management,
5    experimental and investigational treatments, managed care
6    provisions, and other terms and conditions of the
7    insurance policy, of any inpatient admission,
8    detoxification or withdrawal management program admission,
9    or partial hospitalization admission services for the
10    treatment of a mental, emotional, nervous, or substance
11    use disorder or condition related to pregnancy or
12    postpartum complications received 48 hours after the
13    initiation of such services. If an insurer determines that
14    the services are no longer medically necessary, then the
15    covered person shall have the right to external review
16    pursuant to the requirements of the Health Carrier
17    External Review Act.
18        (5) If an insurer determines that continued inpatient
19    care, detoxification or withdrawal management, partial
20    hospitalization, intensive outpatient treatment, or
21    outpatient treatment in a facility is no longer medically
22    necessary, the insurer shall, within 24 hours, provide
23    written notice to the covered pregnant or postpartum
24    individual and the covered pregnant or postpartum
25    individual's provider of its decision and the right to
26    file an expedited internal appeal of the determination.

 

 

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1    The insurer shall review and make a determination with
2    respect to the internal appeal within 24 hours and
3    communicate such determination to the covered pregnant or
4    postpartum individual and the covered pregnant or
5    postpartum individual's provider. If the determination is
6    to uphold the denial, the covered pregnant or postpartum
7    individual and the covered pregnant or postpartum
8    individual's provider have the right to file an expedited
9    external appeal. An independent utilization review
10    organization shall make a determination within 72 hours.
11    If the insurer's determination is upheld and it is
12    determined that continued inpatient care, detoxification
13    or withdrawal management, partial hospitalization,
14    intensive outpatient treatment, or outpatient treatment is
15    not medically necessary, the insurer shall remain
16    responsible for providing benefits for the inpatient care,
17    detoxification or withdrawal management, partial
18    hospitalization, intensive outpatient treatment, or
19    outpatient treatment through the day following the date
20    the determination is made, and the covered pregnant or
21    postpartum individual shall only be responsible for any
22    applicable copayment, deductible, and coinsurance for the
23    stay through that date as applicable under the policy. The
24    covered pregnant or postpartum individual shall not be
25    discharged or released from the inpatient facility,
26    detoxification or withdrawal management, partial

 

 

10300HB5282ham001- 6 -LRB103 38746 RPS 71778 a

1    hospitalization, intensive outpatient treatment, or
2    outpatient treatment until all internal appeals and
3    independent utilization review organization appeals are
4    exhausted. A decision to reverse an adverse determination
5    shall comply with the Health Carrier External Review Act.
6        (6) Except as otherwise stated in this subsection (b),
7    the benefits and cost-sharing shall be provided to the
8    same extent as for any other medical condition covered
9    under the policy.
10        (7) The benefits required by paragraphs (2) and (6) of
11    this subsection (b) are to be provided to (i) all covered
12    pregnant or postpartum individuals with a diagnosis of a
13    mental, emotional, nervous, or substance use disorder or
14    condition and (ii) all individuals who have experienced a
15    miscarriage or stillbirth. The presence of additional
16    related or unrelated diagnoses shall not be a basis to
17    reduce or deny the benefits required by this subsection
18    (b).
19(Source: P.A. 102-665, eff. 10-8-21.)
 
20    Section 99. Effective date. This Act takes effect January
211, 2026.".