HR 953 IH
108th CONGRESS
1st Session
H. R. 953
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 HOUSE OF REPRESENTATIVES
February 27, 2003
Mr. KENNEDY of Rhode Island (for himself, Mr. RAMSTAD, Mr. SMITH of New
Jersey, Mr. STARK, Mr. MURTHA, Mr. LANGEVIN, Mr. SERRANO, Mr. ABERCROMBIE, Mr.
GEORGE MILLER of California, Mrs. NAPOLITANO, Ms. JACKSON-LEE of Texas, Mr.
ANDREWS, Mr. BECERRA, Ms. BERKLEY, Ms. CARSON of Indiana, Mr. FARR, Mr. FATTAH,
Mr. GREEN of Texas, Mr. GUTIERREZ, Mr. HOLDEN, Mr. LARSON of Connecticut, Ms.
LEE, Mrs. MALONEY, Mr. MATSUI, Mr. MEEHAN, Mr. MENENDEZ, Mr. MOLLOHAN, Mr. MORAN
of Virginia, Ms. NORTON, Mr. PALLONE, Ms. PELOSI, Mr. UDALL of New Mexico, Mr.
WEINER, Mr. BISHOP of New York, Mr. CAPUANO, Mr. HOLT, Mr. MCDERMOTT, Mr. OWENS,
Mr. STRICKLAND, Mr. BALLANCE, Mr. COSTELLO, Mr. GARY G. MILLER of California,
Mr. RYAN of Ohio, Ms. WOOLSEY, Mr. LEVIN, Mr. CARDIN, Mr. CASE, Mrs.
CHRISTENSEN, Mr. EMANUEL, Mr. ENGLISH, Mr. FOLEY, Mr. FRELINGHUYSEN, Mr.
GILCHREST, Mr. HOEFFEL, Mr. HONDA, Mr. INSLEE, Mr. KIND, Mr. LATOURETTE, Mr.
LEACH, Mr. MCNULTY, Mr. OBERSTAR, Mr. OLVER, Mr. RANGEL, Ms. SCHAKOWSKY, Mr.
SCHIFF, Mr. WAXMAN, Mr. WYNN, Mr. DEFAZIO, Ms. DELAURO, Mr. DOGGETT, Mr. FROST,
Mrs. JONES of Ohio, Mr. KILDEE, Mr. KLECZKA, Mrs. MCCARTHY of New York, Mr.
MCHUGH, Mr. NADLER, Mr. PASTOR, Mr. SCOTT of Virginia, Mr. SKELTON, Mr. TIERNEY,
Mr. VAN HOLLEN, Mr. ACKERMAN, Mr. BLUMENAUER, Mr. BRADY of Pennsylvania, Ms.
DEGETTE, Mr. DICKS, Mr. DINGELL, Mr. LOBIONDO, Ms. MCCOLLUM, Ms. ROYBAL-ALLARD,
Mr. SANDERS, Mr. SHAYS, Ms. SOLIS, Mr. BERRY, Ms. BORDALLO, Mr. BROWN of Ohio,
Mr. DELAHUNT, Mr. GREENWOOD, Mr. GRIJALVA, Mr. PASCRELL, Mr. PLATTS, Mr. QUINN,
Mr. SAXTON, Mr. SIMMONS, Mrs. TAUSCHER, Mr. DOYLE, Mr. FORD, Mr. HINCHEY, Mr.
RODRIGUEZ, Mr. VISCLOSKY, Mr. BURNS, Mr. DEUTSCH, Mr. ENGEL, Mr. ETHERIDGE, Ms.
KILPATRICK, Mr. ROTHMAN, Mr. ALLEN, Mr. DAVIS of Florida, Mr. FALEOMAVAEGA, Mr.
NORWOOD, Mr. TOWNS, Mr. BACA, Mr. CARSON of Oklahoma, Mr. PAYNE, Mr. PRICE of
North Carolina, Mr. THOMPSON of California, Ms. WATSON, Mr. BERMAN, Mr. COOPER,
Mr. DAVIS of Illinois, Mr. DAVIS of Tennessee, Mrs. KELLY, Mr. KIRK, Mr. LARSEN
of Washington, Mr. RAHALL, Ms. LORETTA SANCHEZ of California, Mr. WAMP, Mr.
CLYBURN, Ms. HOOLEY of Oregon, Mr. KUCINICH, Mr. BOEHLERT, Mr. MATHESON, Mr.
ORTIZ, Ms. SLAUGHTER, Mr. SNYDER, Mr. WALSH, Mr. MURPHY, Mr. SWEENEY, Mr.
LIPINSKI, Mr. MCGOVERN, Mr. BAIRD, Mr. STUPAK, Mr. WILSON of South Carolina, Mr.
BOUCHER, Ms. CORRINE BROWN of Florida, Mrs. CAPPS, Mr. CONYERS, Mrs. DAVIS of
California, Mrs. LOWEY, Mr. PETERSON of Minnesota, and Mr. SABO) introduced the
following bill; which was referred to the Committee on Education and the
Workforce, and in addition to the Committee on Energy and Commerce, for a period
to be subsequently determined by the Speaker, in each case for consideration of
such provisions as fall within the jurisdiction of the committee concerned
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. AMENDMENTS 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) CLERICAL AMENDMENT- The table of contents in section 1 of such Act is
amended by striking the item relating to section 712 and inserting the
following new item:
`Sec. 712. Mental health parity.'.
(c) EFFECTIVE DATE- The amendments 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 also shall include an estimation of the costs of extending the
provisions of such amendments to 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