Overview
On January 1, 2026, Illinois House Bill (HB) 5295 becomes effective. The legislation provides that, under the Illinois Insurance Code, coverage for hormonal and non-hormonal therapies for menopause care is mandatory for all group and individual insurance managed care and Medicaid plans, in certain circumstances.
In Depth
In February 2024, State Representative Laura Faver Dias introduced HB 5295 to ensure that all people going through menopause have sufficient medical care, regardless of their income. In July 2024, Illinois enacted the legislation, which amended two critical aspects of the Illinois statutes related to healthcare insurance coverage and added a new section to the insurance code related to coverage under the Medicaid program.
The legislation amended 215 ILCS 5/356z.56, related to all group, individual, and managed care plans in the state, as follows:
A group or individual policy of accident and health insurance or a managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 shall provide coverage for medically necessary hormonal and non-hormonal therapy to treat menopausal symptoms if the therapy is recommended by a qualified health care provider who is licensed, accredited, or certified under Illinois law and the therapy has been proven safe and effective in peer-reviewed scientific studies. Coverage for therapy to treat menopausal symptoms shall include all federal Food and Drug Administration-approved modalities of hormonal and non-hormonal administration, including, but not limited to, oral, transdermal, topical, and vaginal rings.
The legislation also created a new section, codified at 305 ILCS 5/5-52, that provides coverage for hormonal therapy for medically necessary treatment for menopause that has been induced by a hysterectomy. On November 12, 2024, the Illinois Department of Healthcare and Family Services issued a provider notice confirming the above coverage and its applicability to fee-for-service Medicaid and Medicaid managed care plans.
Why it matters
- These updates remove barriers to coverage for patients seeking medically necessary menopause care.
- The updates acknowledge the impact of peer-reviewed scientific studies and developments in the medical community that have supported the safety and efficacy of both hormonal and non-hormonal therapy.
- Providers, including digital health platforms, that provide covered services to Illinois patients should be aware that services will be reimbursed by plans starting in 2026.
If you have any questions about the new law, please reach out to one of the authors or your regular McDermott Will & Schulte lawyer.