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108th CONGRESS
1st Session
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.
``(b) Construction.--
``(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.
``(b) Construction.--
``(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).
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