IL HB5498

Effective August 16, 2019, requires insurers to provide coverage for diagnosis and medically necessary treatment of mental, emotional, nervous, and substance use disorders consistent with parity requirements and clinical guidelines from organizations like ASAM, LOCUS, CALOCUS, ECSII, and CASII.

Defines "medically necessary treatment" as items or services recommended by treatment providers, furnished in appropriate settings, provided in sufficient amount and duration, and consistent with generally accepted standards of practice based on peer-reviewed evidence or clinical specialty society recommendations.

Prohibits insurers from limiting benefits for chronic or pervasive mental health or substance use disorders to short-term treatment or symptom management, and requires coverage of out-of-network services if medically necessary services are unavailable in-network within required geography and timeliness standards.

Mandates that both the Department of Insurance and Department of Healthcare and Family Services appoint Mental Health and Substance Use Disorder Parity Compliance Officers and conduct parity compliance examinations, with findings made public.

Imposes penalties ranging from $100 to $50,000 per violation per beneficiary (up to $3,000,000 annually per product line) for insurers failing to meet coverage requirements, with penalties adjusted annually for inflation and not subject to time limits.