S 486 IS
108th CONGRESS
1st Session
The Sen. Paul Wellstone Mental Health Parity Act as
presented to the Senate
S. 486
To provide for equal coverage of mental health benefits with respect
to health insurance coverage unless comparable limitations are imposed on
medical and surgical benefits.
IN THE SENATE OF THE UNITED STATES
February 27, 2003
Mr. Domenici (for himself, Mr. Kennedy, Mr. Coleman, Mr. Dayton, Mr.
Grassley, Mr. Reed, Mr. Cochran, Mr. Dodd, Mr. Warner, Mr. Reid, Mr. Thomas, Mr.
Johnson, Mr. Specter, Mr. Harkin, Mr. Lugar, Mr. Daschle, Mr. Graham of South
Carolina, Mrs. Murray, Ms. Collins, Ms. Cantwell, Mr. Roberts, Mr. Edwards, Mr.
Chafee, Mrs. Lincoln, Mr. Bennett, and Mr. Lautenberg) introduced the following
bill; which was read twice and referred to the Committee on Health, Education,
Labor, and Pensions
A BILL
To provide for equal coverage of mental health benefits with respect
to health insurance coverage unless comparable limitations are imposed on
medical and surgical benefits.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Senator Paul Wellstone Mental Health Equitable
Treatment Act of 2003'.
SEC. 2. AMENDMENT TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) IN GENERAL- Section 712 of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1185a) is amended to read as follows:
`SEC. 712. MENTAL HEALTH PARITY.
`(a) IN GENERAL- In the case of a group health plan (or health insurance
coverage offered in connection with such a plan) that provides both medical
and surgical benefits and mental health benefits, such plan or coverage
shall not impose any treatment limitations or financial requirements with
respect to the coverage of benefits for mental illnesses unless comparable
treatment limitations or financial requirements are imposed on medical and
surgical benefits.
`(1) IN GENERAL- Nothing in this section shall be construed as requiring
a group health plan (or health insurance coverage offered in connection
with such a plan) to provide any mental health benefits.
`(2) MEDICAL MANAGEMENT OF MENTAL HEALTH BENEFITS- Consistent with
subsection (a), nothing in this section shall be construed to prevent
the medical management of mental health benefits, including through
concurrent and retrospective utilization review and utilization
management practices, preauthorization, and the application of medical
necessity and appropriateness criteria applicable to behavioral health
and the contracting and use of a network of participating providers.
`(3) NO REQUIREMENT OF SPECIFIC SERVICES- Nothing in this section shall
be construed as requiring a group health plan (or health insurance
coverage offered in connection with such a plan) to provide coverage for
specific mental health services, except to the extent that the failure
to cover such services would result in a disparity between the coverage
of mental health and medical and surgical benefits.
`(c) SMALL EMPLOYER EXEMPTION-
`(1) IN GENERAL- This section shall not apply to any group health plan
(and group health insurance coverage offered in connection with a group
health plan) for any plan year of any employer who employed an average
of at least 2 but not more than 50 employees on business days during the
preceding calendar year.
`(2) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE- For
purposes of this subsection--
`(A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS- Rules similar to
the rules under subsections (b), (c), (m), and (o) of section 414 of
the Internal Revenue Code of 1986 shall apply for purposes of
treating persons as a single employer.
`(B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR- In the case of an
employer which was not in existence throughout the preceding
calendar year, the determination of whether such employer is a small
employer shall be based on the average number of employees that it
is reasonably expected such employer will employ on business days in
the current calendar year.
`(C) PREDECESSORS- Any reference in this paragraph to an employer
shall include a reference to any predecessor of such employer.
`(d) SEPARATE APPLICATION TO EACH OPTION OFFERED- In the case of a group
health plan that offers a participant or beneficiary two or more benefit
package options under the plan, the requirements of this section shall be
applied separately with respect to each such option.
`(e) IN-NETWORK AND OUT-OF-NETWORK RULES- In the case of a plan or coverage
option that provides in-network mental health benefits, out-of-network
mental health benefits may be provided using treatment limitations or
financial requirements that are not comparable to the limitations and
requirements applied to medical and surgical benefits if the plan or
coverage provides such in-network mental health benefits in accordance with
subsection (a) and provides reasonable access to in-network providers and
facilities.
`(f) DEFINITIONS- For purposes of this section--
`(1) FINANCIAL REQUIREMENTS- The term `financial requirements' includes
deductibles, coinsurance, co-payments, other cost sharing, and
limitations on the total amount that may be paid by a participant or
beneficiary with respect to benefits under the plan or health insurance
coverage and shall include the application of annual and lifetime
limits.
`(2) MEDICAL OR SURGICAL BENEFITS- The term `medical or surgical
benefits' means benefits with respect to medical or surgical services,
as defined under the terms of the plan or coverage (as the case may be),
but does not include mental health benefits.
`(3) MENTAL HEALTH BENEFITS- The term `mental health benefits' means
benefits with respect to services, as defined under the terms and
conditions of the plan or coverage (as the case may be), for all
categories of mental health conditions listed in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM IV-TR), or
the most recent edition if different than the Fourth Edition, if such
services are included as part of an authorized treatment plan that is in
accordance with standard protocols and such services meet the plan or
issuer's medical necessity criteria. Such term does not include benefits
with respect to the treatment of substance abuse or chemical dependency.
`(4) TREATMENT LIMITATIONS- The term `treatment limitations' means
limitations on the frequency of treatment, number of visits or days of
coverage, or other similar limits on the duration or scope of treatment
under the plan or coverage.'.
(b) EFFECTIVE DATE- The amendment made by this section shall apply with
respect to plan years beginning on or after January 1, 2004.
SEC. 3. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE GROUP
MARKET.
(a) IN GENERAL- Section 2705 of the Public Health Service Act (42 U.S.C.
300gg-5) is amended to read as follows:
`SEC. 2705. MENTAL HEALTH PARITY.
`(a) IN GENERAL- In the case of a group health plan (or health insurance
coverage offered in connection with such a plan) that provides both medical
and surgical benefits and mental health benefits, such plan or coverage
shall not impose any treatment limitations or financial requirements with
respect to the coverage of benefits for mental illnesses unless comparable
treatment limitations or financial requirements are imposed on medical and
surgical benefits.
`(1) IN GENERAL- Nothing in this section shall be construed as requiring
a group health plan (or health insurance coverage offered in connection
with such a plan) to provide any mental health benefits.
`(2) MEDICAL MANAGEMENT OF MENTAL HEALTH BENEFITS- Consistent with
subsection (a), nothing in this section shall be construed to prevent
the medical management of mental health benefits, including through
concurrent and retrospective utilization review and utilization
management practices, preauthorization, and the application of medical
necessity and appropriateness criteria applicable to behavioral health
and the contracting and use of a network of participating providers.
`(3) NO REQUIREMENT OF SPECIFIC SERVICES- Nothing in this section shall
be construed as requiring a group health plan (or health insurance
coverage offered in connection with such a plan) to provide coverage for
specific mental health services, except to the extent that the failure
to cover such services would result in a disparity between the coverage
of mental health and medical and surgical benefits.
`(c) SMALL EMPLOYER EXEMPTION-
`(1) IN GENERAL- This section shall not apply to any group health plan
(and group health insurance coverage offered in connection with a group
health plan) for any plan year of any employer who employed an average
of at least 2 but not more than 50 employees on business days during the
preceding calendar year.
`(2) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE- For
purposes of this subsection--
`(A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS- Rules similar to
the rules under subsections (b), (c), (m), and (o) of section 414 of
the Internal Revenue Code of 1986 shall apply for purposes of
treating persons as a single employer.
`(B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR- In the case of an
employer which was not in existence throughout the preceding
calendar year, the determination of whether such employer is a small
employer shall be based on the average number of employees that it
is reasonably expected such employer will employ on business days in
the current calendar year.
`(C) PREDECESSORS- Any reference in this paragraph to an employer
shall include a reference to any predecessor of such employer.
`(d) SEPARATE APPLICATION TO EACH OPTION OFFERED- In the case of a group
health plan that offers a participant or beneficiary two or more benefit
package options under the plan, the requirements of this section shall be
applied separately with respect to each such option.
`(e) IN-NETWORK AND OUT-OF-NETWORK RULES- In the case of a plan or coverage
option that provides in-network mental health benefits, out-of-network
mental health benefits may be provided using treatment limitations or
financial requirements that are not comparable to the limitations and
requirements applied to medical and surgical benefits if the plan or
coverage provides such in-network mental health benefits in accordance with
subsection (a) and provides reasonable access to in-network providers and
facilities.
`(f) DEFINITIONS- For purposes of this section--
`(1) FINANCIAL REQUIREMENTS- The term `financial requirements' includes
deductibles, coinsurance, co-payments, other cost sharing, and
limitations on the total amount that may be paid by a participant,
beneficiary or enrollee with respect to benefits under the plan or
health insurance coverage and shall include the application of annual
and lifetime limits.
`(2) MEDICAL OR SURGICAL BENEFITS- The term `medical or surgical
benefits' means benefits with respect to medical or surgical services,
as defined under the terms of the plan or coverage (as the case may be),
but does not include mental health benefits.
`(3) MENTAL HEALTH BENEFITS- The term `mental health benefits' means
benefits with respect to services, as defined under the terms and
conditions of the plan or coverage (as the case may be), for all
categories of mental health conditions listed in the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM IV-TR), or
the most recent edition if different than the Fourth Edition, if such
services are included as part of an authorized treatment plan that is in
accordance with standard protocols and such services meet the plan or
issuer's medical necessity criteria. Such term does not include benefits
with respect to the treatment of substance abuse or chemical dependency.
`(4) TREATMENT LIMITATIONS- The term `treatment limitations' means
limitations on the frequency of treatment, number of visits or days of
coverage, or other similar limits on the duration or scope of treatment
under the plan or coverage.'.
(b) EFFECTIVE DATE- The amendment made by this section shall apply with
respect to plan years beginning on or after January 1, 2004.
SEC. 4. PREEMPTION.
Nothing in the amendments made by this Act shall be construed to preempt any
provision of State law, with respect to health insurance coverage offered by
a health insurance issuer in connection with a group health plan, that
provides protections to enrollees that are greater than the protections
provided under such amendments. Nothing in the amendments made by this Act
shall be construed to affect or modify section 514 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1144).
SEC. 5. GENERAL ACCOUNTING OFFICE STUDY.
(a) STUDY- The Comptroller General shall conduct a study that evaluates the
effect of the implementation of the amendments made by this Act on the cost
of health insurance coverage, access to health insurance coverage (including
the availability of in-network providers), the quality of health care, and
other issues as determined appropriate by the Comptroller General. Such
study shall also include an estimate of the cost that would be incurred if
such amendments were extended in a manner so as to provide coverage for the
treatment of substance abuse and chemical dependency.
(b) REPORT- Not later than 2 years after the date of enactment of this Act,
the Comptroller General shall prepare and submit to the appropriate
committees of Congress a report containing the results of the study
conducted under subsection (a).
END
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