Public Act 103-0701
 
HB5282 EnrolledLRB103 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.)
 
    Section 99. Effective date. This Act takes effect January 
1, 2026.