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HB4500 - 104th General Assembly

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House Amendment 001

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104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB4500

Introduced 1/20/2026, by Rep. Margaret Croke

SYNOPSIS AS INTRODUCED:

215 ILCS 5/356z.40

Amends the Illinois Insurance Code. Provides that, for policies of
accident and health insurance amended, delivered, issued, or renewed on or
after January 1, 2027, coverage for pregnancy and postpartum care shall
include medically necessary blood pressure monitors for pregnant or
postpartum insured persons or beneficiaries. Effective immediately.
LRB104 17655 BAB 31086 b

A BILL FOR

HB4500
LRB104 17655 BAB 31086 b
1

AN ACT concerning regulation.

2

Be it enacted by the People of the State of Illinois,
3
represented in the General Assembly:

4

Section 25.
The Illinois Insurance Code is amended by
5
adding 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
9
insurance or managed care plan amended, delivered, issued, or
10
renewed on or after October 8, 2021 (the effective date of
11
Public Act 102-665) shall provide coverage for pregnancy and
12
newborn care in accordance with 42 U.S.C. 18022(b) regarding
13
essential health benefits. For policies amended, delivered,
14
issued, or renewed on or after January 1, 2026, this
15
subsection also applies to coverage for postpartum care.
16

(b) Benefits under this Section shall be as follows:
17

(1) An individual who has been identified as
18

experiencing a high-risk pregnancy by the individual's
19

treating provider shall have access to clinically
20

appropriate case management programs. As used in this
21

subsection, "case management" means a mechanism to
22

coordinate and assure continuity of services, including,
23

but not limited to, health services, social services, and

HB4500
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LRB104 17655 BAB 31086 b
1

educational services necessary for the individual. "Case
2

management" involves individualized assessment of needs,
3

planning of services, referral, monitoring, and advocacy
4

to assist an individual in gaining access to appropriate
5

services and closure when services are no longer required.
6

"Case management" is an active and collaborative process
7

involving a single qualified case manager, the individual,
8

the individual's family, the providers, and the community.
9

This includes close coordination and involvement with all
10

service providers in the management plan for that
11

individual or family, including assuring that the
12

individual receives the services. As used in this
13

subsection, "high-risk pregnancy" means a pregnancy in
14

which the pregnant or postpartum individual or baby is at
15

an increased risk for poor health or complications during
16

pregnancy or childbirth, including, but not limited to,
17

hypertension disorders, gestational diabetes, and
18

hemorrhage.
19

(2) An individual shall have access to medically
20

necessary treatment of a mental, emotional, nervous, or
21

substance use disorder or condition consistent with the
22

requirements set forth in this Section and in Sections
23

370c and 370c.1 of this Code. Prior authorization
24

requirements are prohibited to the extent provided in
25

Section 370c.
26

(3) The benefits provided for inpatient and outpatient

HB4500
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LRB104 17655 BAB 31086 b
1

services for the medically necessary treatment of a
2

mental, emotional, nervous, or substance use disorder or
3

condition related to pregnancy or postpartum complications
4

shall be provided consistent with the requirements of
5

Sections 370c and 370c.1 of this Code. The facility or
6

provider shall notify the insurer of both the admission
7

and the initial treatment plan within 48 hours after
8

admission or initiation of treatment. Subject to the
9

requirements of Sections 370c and 370c.1 of this Code,
10

nothing in this paragraph shall prevent an insurer from
11

applying concurrent and post-service utilization review of
12

health care services, including review of medical
13

necessity, case management, experimental and
14

investigational treatments, managed care provisions, and
15

other terms and conditions of the insurance policy.
16

(4) The benefits for the first 48 hours of initiation
17

of services for an inpatient admission, detoxification or
18

withdrawal management program, or partial hospitalization
19

admission for the treatment of a mental, emotional,
20

nervous, or substance use disorder or condition related to
21

pregnancy or postpartum complications shall be provided
22

without post-service or concurrent review of medical
23

necessity, as the medical necessity for the first 48 hours
24

of such services shall be determined solely by the covered
25

pregnant or postpartum individual's provider. Subject to
26

Sections 370c and 370c.1 of this Code, nothing in this

HB4500
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LRB104 17655 BAB 31086 b
1

paragraph shall prevent an insurer from applying
2

concurrent and post-service utilization review, including
3

the review of medical necessity, case management,
4

experimental and investigational treatments, managed care
5

provisions, and other terms and conditions of the
6

insurance policy, of any inpatient admission,
7

detoxification or withdrawal management program admission,
8

or partial hospitalization admission services for the
9

treatment of a mental, emotional, nervous, or substance
10

use disorder or condition related to pregnancy or
11

postpartum complications received 48 hours after the
12

initiation of such services. If an insurer determines that
13

the services are no longer medically necessary, then the
14

covered person shall have the right to external review
15

pursuant to the requirements of the Health Carrier
16

External Review Act.
17

(5) If an insurer determines that continued inpatient
18

care, detoxification or withdrawal management, partial
19

hospitalization, intensive outpatient treatment, or
20

outpatient treatment in a facility is no longer medically
21

necessary, the insurer shall, within 24 hours, provide
22

written notice to the covered pregnant or postpartum
23

individual and the covered pregnant or postpartum
24

individual's provider of its decision and the right to
25

file an expedited internal appeal of the determination.
26

The insurer shall review and make a determination with

HB4500
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LRB104 17655 BAB 31086 b
1

respect to the internal appeal within 24 hours and
2

communicate such determination to the covered pregnant or
3

postpartum individual and the covered pregnant or
4

postpartum individual's provider. If the determination is
5

to uphold the denial, the covered pregnant or postpartum
6

individual and the covered pregnant or postpartum
7

individual's provider have the right to file an expedited
8

external appeal. An independent review organization shall
9

make a determination within 72 hours. If the insurer's
10

determination is upheld and it is determined that
11

continued inpatient care, detoxification or withdrawal
12

management, partial hospitalization, intensive outpatient
13

treatment, or outpatient treatment is not medically
14

necessary, or if the insurer's determination is not
15

appealed, the insurer shall remain responsible for
16

providing benefits for the inpatient care, detoxification
17

or withdrawal management, partial hospitalization,
18

intensive outpatient treatment, or outpatient treatment
19

through the day following the date the determination is
20

made, and the covered pregnant or postpartum individual
21

shall only be responsible for any applicable copayment,
22

deductible, and coinsurance for the stay through that date
23

as applicable under the policy. The covered pregnant or
24

postpartum individual shall not be discharged or released
25

from the inpatient facility, detoxification or withdrawal
26

management, partial hospitalization, intensive outpatient

HB4500
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LRB104 17655 BAB 31086 b
1

treatment, or outpatient treatment until all internal
2

appeals and independent utilization review organization
3

appeals are exhausted. A decision to reverse an adverse
4

determination shall comply with the Health Carrier
5

External Review Act.
6

(6) Except as otherwise stated in this subsection (b)
7

and subsection (c), the benefits and cost-sharing shall be
8

provided to the same extent as for any other medical
9

condition covered 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

(8) Insurers shall cover all services for pregnancy,
20

postpartum, and newborn care that are rendered by
21

perinatal doulas or licensed certified professional
22

midwives, including home births, home visits, and support
23

during labor, abortion, or miscarriage. Coverage shall
24

include the necessary equipment and medical supplies for a
25

home birth. For home visits by a perinatal doula, not
26

counting any home birth, the policy may limit coverage to

HB4500
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LRB104 17655 BAB 31086 b
1

16 visits before and 16 visits after a birth, miscarriage,
2

or abortion, provided that the policy shall not be
3

required to cover more than $8,000 for doula visits for
4

each pregnancy and subsequent postpartum period. As used
5

in this paragraph (8), "perinatal doula" has the meaning
6

given in subsection (a) of Section 5-18.5 of the Illinois
7

Public Aid Code.
8

(9) Coverage for pregnancy, postpartum, and newborn
9

care shall include home visits by lactation consultants
10

and the purchase of breast pumps and breast pump supplies,
11

including such breast pumps, breast pump supplies,
12

breastfeeding supplies, and feeding aids as recommended by
13

the lactation consultant. As used in this paragraph (9),
14

"lactation consultant" means an International
15

Board-Certified Lactation Consultant, a certified
16

lactation specialist with a certification from Lactation
17

Education Consultants, or a certified lactation counselor
18

as defined in subsection (a) of Section 5-18.10 of the
19

Illinois Public Aid Code.
20

(9.5) For policies of accident and health insurance
21

amended, delivered, issued, or renewed on or after January
22

1, 2027, coverage for pregnancy and postpartum care shall
23

include medically necessary blood pressure monitors for
24

pregnant or postpartum insured persons or beneficiaries.

25

(10) Coverage for postpartum services shall apply for
26

all covered services rendered within the first 12 months

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LRB104 17655 BAB 31086 b
1

after the end of pregnancy, subject to any policy
2

limitation on home visits by a perinatal doula allowed
3

under paragraph (8) of this subsection (b). Nothing in
4

this paragraph (10) shall be construed to require a policy
5

to cover services for an individual who is no longer
6

insured or enrolled under the policy. If an individual
7

becomes insured or enrolled under a new policy, the new
8

policy shall cover the individual consistent with the time
9

period and limitations allowed under this paragraph (10).
10

This paragraph (10) is subject to the requirements of
11

Section 25 of the Managed Care Reform and Patient Rights
12

Act, Section 20 of the Network Adequacy and Transparency
13

Act, and 42 U.S.C. 300gg-113.
14

(c) All coverage described in subsection (b), other than
15
health care services for home births, shall be provided
16
without cost-sharing, except that, for mental health services,
17
the cost-sharing prohibition does not apply to inpatient or
18
residential services, and, for substance use disorder
19
services, the cost-sharing prohibition applies only to levels
20
of treatment below and not including Level 3.1 (Clinically
21
Managed Low-Intensity Residential), as established by the
22
American Society for Addiction Medicine. This subsection does
23
not apply to the extent such coverage would disqualify a
24
high-deductible health plan from eligibility for a health
25
savings account pursuant to Section 223 of the Internal
26
Revenue Code.

HB4500
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LRB104 17655 BAB 31086 b
1
(Source: P.A. 103-650, eff. 1-1-25; 103-701, eff. 1-1-26;
2
103-720, eff. 1-1-26; 104-28, eff. 1-1-26; 104-417, eff.
3
8-15-25
.)

4

Section 99.
Effective date.
This Act takes effect upon
5
becoming law.

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