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| SEC. 512. Mental Health Parity (Can someone translate what this means?)
| Anonymous Coward
User ID: 490625
10/1/2008 11:07 PM
Report abusive post | SEC. 512. Mental Health Parity (Can someone translate what this means?)
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SEC. 512. MENTAL HEALTH PARITY. 16
(a) AMENDMENTS TO ERISA.—Section 712 of the 17
Employee Retirement Income Security Act of 1974 (29 18
U.S.C. 1185a) is amended— 19
(1) in subsection (a), by adding at the end the 20
following: 21
‘‘(3) FINANCIAL REQUIREMENTS AND TREAT- 22
MENT LIMITATIONS.— 23
‘‘(A) IN GENERAL.—In the case of a group 24
health plan (or health insurance coverage of- 25
311
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fered in connection with such a plan) that pro- 1
vides both medical and surgical benefits and 2
mental health or substance use disorder bene- 3
fits, such plan or coverage shall ensure that— 4
‘‘(i) the financial requirements appli- 5
cable to such mental health or substance 6
use disorder benefits are no more restric- 7
tive than the predominant financial re- 8
quirements applied to substantially all 9
medical and surgical benefits covered by 10
the plan (or coverage), and there are no 11
separate cost sharing requirements that 12
are applicable only with respect to mental 13
health or substance use disorder benefits; 14
and 15
‘‘(ii) the treatment limitations applica- 16
ble to such mental health or substance use 17
disorder benefits are no more restrictive 18
than the predominant treatment limita- 19
tions applied to substantially all medical 20
and surgical benefits covered by the plan 21
(or coverage) and there are no separate 22
treatment limitations that are applicable 23
only with respect to mental health or sub- 24
stance use disorder benefits. 25
312
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‘‘(B) DEFINITIONS.—In this paragraph: 1
‘‘(i) FINANCIAL REQUIREMENT.—The 2
term ‘financial requirement’ includes 3
deductibles, copayments, coinsurance, and 4
out-of-pocket expenses, but excludes an ag- 5
gregate lifetime limit and an annual limit 6
subject to paragraphs (1) and (2), 7
‘‘(ii) PREDOMINANT.—A financial re- 8
quirement or treatment limit is considered 9
to be predominant if it is the most com- 10
mon or frequent of such type of limit or 11
requirement. 12
‘‘(iii) TREATMENT LIMITATION.—The 13
term ‘treatment limitation’ includes limits 14
on the frequency of treatment, number of 15
visits, days of coverage, or other similar 16
limits on the scope or duration of treat- 17
ment. 18
‘‘(4) AVAILABILITY OF PLAN INFORMATION.— 19
The criteria for medical necessity determinations 20
made under the plan with respect to mental health 21
or substance use disorder benefits (or the health in- 22
surance coverage offered in connection with the plan 23
with respect to such benefits) shall be made avail- 24
able by the plan administrator (or the health insur- 25
313
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ance issuer offering such coverage) in accordance 1
with regulations to any current or potential partici- 2
pant, beneficiary, or contracting provider upon re- 3
quest. The reason for any denial under the plan (or 4
coverage) of reimbursement or payment for services 5
with respect to mental health or substance use dis- 6
order benefits in the case of any participant or bene- 7
ficiary shall, on request or as otherwise required, be 8
made available by the plan administrator (or the 9
health insurance issuer offering such coverage) to 10
the participant or beneficiary in accordance with 11
regulations. 12
‘‘(5) OUT-OF-NETWORK PROVIDERS.—In the 13
case of a plan or coverage that provides both med- 14
ical and surgical benefits and mental health or sub- 15
stance use disorder benefits, if the plan or coverage 16
provides coverage for medical or surgical benefits 17
provided by out-of-network providers, the plan or 18
coverage shall provide coverage for mental health or 19
substance use disorder benefits provided by out-of- 20
network providers in a manner that is consistent 21
with the requirements of this section.’’; 22
(2) in subsection (b), by amending paragraph 23
(2) to read as follows: 24
314
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‘‘(2) in the case of a group health plan (or 1
health insurance coverage offered in connection with 2
such a plan) that provides mental health or sub- 3
stance use disorder benefits, as affecting the terms 4
and conditions of the plan or coverage relating to 5
such benefits under the plan or coverage, except as 6
provided in subsection (a).’’; 7
(3) in subsection (c)— 8
(A) in paragraph (1)(B)— 9
(i) by inserting ‘‘(or 1 in the case of 10
an employer residing in a State that per- 11
mits small groups to include a single indi- 12
vidual)’’ after ‘‘at least 2’’ the first place 13
that such appears; and 14
(ii) by striking ‘‘and who employs at 15
least 2 employees on the first day of the 16
plan year’’; and 17
(B) by striking paragraph (2) and insert- 18
ing the following: 19
‘‘(2) COST EXEMPTION.— 20
‘‘(A) IN GENERAL.—With respect to a 21
group health plan (or health insurance coverage 22
offered in connection with such a plan), if the 23
application of this section to such plan (or cov- 24
erage) results in an increase for the plan year 25
315
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involved of the actual total costs of coverage 1
with respect to medical and surgical benefits 2
and mental health and substance use disorder 3
benefits under the plan (as determined and cer- 4
tified under subparagraph (C)) by an amount 5
that exceeds the applicable percentage described 6
in subparagraph (B) of the actual total plan 7
costs, the provisions of this section shall not 8
apply to such plan (or coverage) during the fol- 9
lowing plan year, and such exemption shall 10
apply to the plan (or coverage) for 1 plan year. 11
An employer may elect to continue to apply 12
mental health and substance use disorder parity 13
pursuant to this section with respect to the 14
group health plan (or coverage) involved regard- 15
less of any increase in total costs. 16
‘‘(B) APPLICABLE PERCENTAGE.—With re- 17
spect to a plan (or coverage), the applicable 18
percentage described in this subparagraph shall 19
be— 20
‘‘(i) 2 percent in the case of the first 21
plan year in which this section is applied; 22
and 23
‘‘(ii) 1 percent in the case of each 24
subsequent plan year. 25
316
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‘‘(C) DETERMINATIONS BY ACTUARIES.— 1
Determinations as to increases in actual costs 2
under a plan (or coverage) for purposes of this 3
section shall be made and certified by a quali- 4
fied and licensed actuary who is a member in 5
good standing of the American Academy of Ac- 6
tuaries. All such determinations shall be in a 7
written report prepared by the actuary. The re- 8
port, and all underlying documentation relied 9
upon by the actuary, shall be maintained by the 10
group health plan or health insurance issuer for 11
a period of 6 years following the notification 12
made under subparagraph (E). 13
‘‘(D) 6-MONTH DETERMINATIONS.—If a 14
group health plan (or a health insurance issuer 15
offering coverage in connection with a group 16
health plan) seeks an exemption under this 17
paragraph, determinations under subparagraph 18
(A) shall be made after such plan (or coverage) 19
has complied with this section for the first 6 20
months of the plan year involved. 21
‘‘(E) NOTIFICATION.— 22
‘‘(i) IN GENERAL.—A group health 23
plan (or a health insurance issuer offering 24
coverage in connection with a group health 25
317
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plan) that, based upon a certification de- 1
scribed under subparagraph (C), qualifies 2
for an exemption under this paragraph, 3
and elects to implement the exemption, 4
shall promptly notify the Secretary, the ap- 5
propriate State agencies, and participants 6
and beneficiaries in the plan of such elec- 7
tion. 8
‘‘(ii) REQUIREMENT.—A notification 9
to the Secretary under clause (i) shall in- 10
clude— 11
‘‘(I) a description of the number 12
of covered lives under the plan (or 13
coverage) involved at the time of the 14
notification, and as applicable, at the 15
time of any prior election of the cost- 16
exemption under this paragraph by 17
such plan (or coverage); 18
‘‘(II) for both the plan year upon 19
which a cost exemption is sought and 20
the year prior, a description of the ac- 21
tual total costs of coverage with re- 22
spect to medical and surgical benefits 23
and mental health and substance use 24
disorder benefits under the plan; and 25
318
O:AYOAYO08C32.xml S.L.C.
‘‘(III) for both the plan year 1
upon which a cost exemption is sought 2
and the year prior, the actual total 3
costs of coverage with respect to men- 4
tal health and substance use disorder 5
benefits under the plan. 6
‘‘(iii) CONFIDENTIALITY.—A notifica- 7
tion to the Secretary under clause (i) shall 8
be confidential. The Secretary shall make 9
available, upon request and on not more 10
than an annual basis, an anonymous 11
itemization of such notifications, that in- 12
cludes— 13
‘‘(I) a breakdown of States by 14
the size and type of employers submit- 15
ting such notification; and 16
‘‘(II) a summary of the data re- 17
ceived under clause (ii). 18
‘‘(F) AUDITS BY APPROPRIATE AGEN- 19
CIES.—To determine compliance with this para- 20
graph, the Secretary may audit the books and 21
records of a group health plan or health insur- 22
ance issuer relating to an exemption, including 23
any actuarial reports prepared pursuant to sub- 24
paragraph (C), during the 6 year period fol- 25
319
O:AYOAYO08C32.xml S.L.C.
lowing the notification of such exemption under 1
subparagraph (E). A State agency receiving a 2
notification under subparagraph (E) may also 3
conduct such an audit with respect to an ex- 4
emption covered by such notification.’’; 5
(4) in subsection (e), by striking paragraph (4) 6
and inserting the following: 7
‘‘(4) MENTAL HEALTH BENEFITS.—The term 8
‘mental health benefits’ means benefits with respect 9
to services for mental health conditions, as defined 10
under the terms of the plan and in accordance with 11
applicable Federal and State law. 12
‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 13
The term ‘substance use disorder benefits’ means 14
benefits with respect to services for substance use 15
disorders, as defined under the terms of the plan 16
and in accordance with applicable Federal and State 17
law.’’; 18
(5) by striking subsection (f); 19
(6) by inserting after subsection (e) the fol- 20
lowing: 21
‘‘(f) SECRETARY REPORT.—The Secretary shall, by 22
January 1, 2012, and every two years thereafter, submit 23
to the appropriate committees of Congress a report on 24
compliance of group health plans (and health insurance 25
320
O:AYOAYO08C32.xml S.L.C.
coverage offered in connection with such plans) with the 1
requirements of this section. Such report shall include the 2
results of any surveys or audits on compliance of group 3
health plans (and health insurance coverage offered in 4
connection with such plans) with such requirements and 5
an analysis of the reasons for any failures to comply. 6
‘‘(g) NOTICE AND ASSISTANCE.—The Secretary, in 7
cooperation with the Secretaries of Health and Human 8
Services and Treasury, as appropriate, shall publish and 9
widely disseminate guidance and information for group 10
health plans, participants and beneficiaries, applicable 11
State and local regulatory bodies, and the National Asso- 12
ciation of Insurance Commissioners concerning the re- 13
quirements of this section and shall provide assistance 14
concerning such requirements and the continued operation 15
of applicable State law. Such guidance and information 16
shall inform participants and beneficiaries of how they 17
may obtain assistance under this section, including, where 18
appropriate, assistance from State consumer and insur- 19
ance agencies.’’; 20
(7) by striking ‘‘mental health benefits’’ and in- 21
serting ‘‘mental health and substance use disorder 22
benefits’’ each place it appears in subsections 23
(a)(1)(B)(i), (a)(1)(C), (a)(2)(B)(i), and (a)(2)(C); 24
and 25
321
O:AYOAYO08C32.xml S.L.C.
(8) by striking ‘‘mental health benefits’’ and in- 1
serting ‘‘mental health or substance use disorder 2
benefits’’ each place it appears (other than in any 3
provision amended by the previous paragraph). 4
(b) AMENDMENTS TO PUBLIC HEALTH SERVICE 5
ACT.—Section 2705 of the Public Health Service Act (42 6
U.S.C. 300gg–5) is amended— 7
(1) in subsection (a), by adding at the end the 8
following: 9
‘‘(3) FINANCIAL REQUIREMENTS AND TREAT- 10
MENT LIMITATIONS.— 11
‘‘(A) IN GENERAL.—In the case of a group 12
health plan (or health insurance coverage of- 13
fered in connection with such a plan) that pro- 14
vides both medical and surgical benefits and 15
mental health or substance use disorder bene- 16
fits, such plan or coverage shall ensure that— 17
‘‘(i) the financial requirements appli- 18
cable to such mental health or substance 19
use disorder benefits are no more restric- 20
tive than the predominant financial re- 21
quirements applied to substantially all 22
medical and surgical benefits covered by 23
the plan (or coverage), and there are no 24
separate cost sharing requirements that 25
322
O:AYOAYO08C32.xml S.L.C.
are applicable only with respect to mental 1
health or substance use disorder benefits; 2
and 3
‘‘(ii) the treatment limitations applica- 4
ble to such mental health or substance use 5
disorder benefits are no more restrictive 6
than the predominant treatment limita- 7
tions applied to substantially all medical 8
and surgical benefits covered by the plan 9
(or coverage) and there are no separate 10
treatment limitations that are applicable 11
only with respect to mental health or sub- 12
stance use disorder benefits. 13
‘‘(B) DEFINITIONS.—In this paragraph: 14
‘‘(i) FINANCIAL REQUIREMENT.—The 15
term ‘financial requirement’ includes 16
deductibles, copayments, coinsurance, and 17
out-of-pocket expenses, but excludes an ag- 18
gregate lifetime limit and an annual limit 19
subject to paragraphs (1) and (2). 20
‘‘(ii) PREDOMINANT.—A financial re- 21
quirement or treatment limit is considered 22
to be predominant if it is the most com- 23
mon or frequent of such type of limit or 24
requirement. 25
323
O:AYOAYO08C32.xml S.L.C.
‘‘(iii) TREATMENT LIMITATION.—The 1
term ‘treatment limitation’ includes limits 2
on the frequency of treatment, number of 3
visits, days of coverage, or other similar 4
limits on the scope or duration of treat- 5
ment. 6
‘‘(4) AVAILABILITY OF PLAN INFORMATION.— 7
The criteria for medical necessity determinations 8
made under the plan with respect to mental health 9
or substance use disorder benefits (or the health in- 10
surance coverage offered in connection with the plan 11
with respect to such benefits) shall be made avail- 12
able by the plan administrator (or the health insur- 13
ance issuer offering such coverage) in accordance 14
with regulations to any current or potential partici- 15
pant, beneficiary, or contracting provider upon re- 16
quest. The reason for any denial under the plan (or 17
coverage) of reimbursement or payment for services 18
with respect to mental health or substance use dis- 19
order benefits in the case of any participant or bene- 20
ficiary shall, on request or as otherwise required, be 21
made available by the plan administrator (or the 22
health insurance issuer offering such coverage) to 23
the participant or beneficiary in accordance with 24
regulations. 25
324
O:AYOAYO08C32.xml S.L.C.
‘‘(5) OUT-OF-NETWORK PROVIDERS.—In the 1
case of a plan or coverage that provides both med- 2
ical and surgical benefits and mental health or sub- 3
stance use disorder benefits, if the plan or coverage 4
provides coverage for medical or surgical benefits 5
provided by out-of-network providers, the plan or 6
coverage shall provide coverage for mental health or 7
substance use disorder benefits provided by out-of- 8
network providers in a manner that is consistent 9
with the requirements of this section.’’; 10
(2) in subsection (b), by amending paragraph 11
(2) to read as follows: 12
‘‘(2) in the case of a group health plan (or 13
health insurance coverage offered in connection with 14
such a plan) that provides mental health or sub- 15
stance use disorder benefits, as affecting the terms 16
and conditions of the plan or coverage relating to 17
such benefits under the plan or coverage, except as 18
provided in subsection (a).’’; 19
(3) in subsection (c)— 20
(A) in paragraph (1), by inserting before 21
the period the following: ‘‘(as defined in section 22
2791(e)(4), except that for purposes of this 23
paragraph such term shall include employers 24
with 1 employee in the case of an employer re- 25
325
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siding in a State that permits small groups to 1
include a single individual)’’; and 2
(B) by striking paragraph (2) and insert- 3
ing the following: 4
‘‘(2) COST EXEMPTION.— 5
‘‘(A) IN GENERAL.—With respect to a 6
group health plan (or health insurance coverage 7
offered in connection with such a plan), if the 8
application of this section to such plan (or cov- 9
erage) results in an increase for the plan year 10
involved of the actual total costs of coverage 11
with respect to medical and surgical benefits 12
and mental health and substance use disorder 13
benefits under the plan (as determined and cer- 14
tified under subparagraph (C)) by an amount 15
that exceeds the applicable percentage described 16
in subparagraph (B) of the actual total plan 17
costs, the provisions of this section shall not 18
apply to such plan (or coverage) during the fol- 19
lowing plan year, and such exemption shall 20
apply to the plan (or coverage) for 1 plan year. 21
An employer may elect to continue to apply 22
mental health and substance use disorder parity 23
pursuant to this section with respect to the 24
326
O:AYOAYO08C32.xml S.L.C.
group health plan (or coverage) involved regard- 1
less of any increase in total costs. 2
‘‘(B) APPLICABLE PERCENTAGE.—With re- 3
spect to a plan (or coverage), the applicable 4
percentage described in this subparagraph shall 5
be— 6
‘‘(i) 2 percent in the case of the first 7
plan year in which this section is applied; 8
and 9
‘‘(ii) 1 percent in the case of each 10
subsequent plan year. 11
‘‘(C) DETERMINATIONS BY ACTUARIES.— 12
Determinations as to increases in actual costs 13
under a plan (or coverage) for purposes of this 14
section shall be made and certified by a quali- 15
fied and licensed actuary who is a member in 16
good standing of the American Academy of Ac- 17
tuaries. All such determinations shall be in a 18
written report prepared by the actuary. The re- 19
port, and all underlying documentation relied 20
upon by the actuary, shall be maintained by the 21
group health plan or health insurance issuer for 22
a period of 6 years following the notification 23
made under subparagraph (E). 24
327
O:AYOAYO08C32.xml S.L.C.
‘‘(D) 6-MONTH DETERMINATIONS.—If a 1
group health plan (or a health insurance issuer 2
offering coverage in connection with a group 3
health plan) seeks an exemption under this 4
paragraph, determinations under subparagraph 5
(A) shall be made after such plan (or coverage) 6
has complied with this section for the first 6 7
months of the plan year involved. 8
‘‘(E) NOTIFICATION.— 9
‘‘(i) IN GENERAL.—A group health 10
plan (or a health insurance issuer offering 11
coverage in connection with a group health 12
plan) that, based upon a certification de- 13
scribed under subparagraph (C), qualifies 14
for an exemption under this paragraph, 15
and elects to implement the exemption, 16
shall promptly notify the Secretary, the ap- 17
propriate State agencies, and participants 18
and beneficiaries in the plan of such elec- 19
tion. 20
‘‘(ii) REQUIREMENT.—A notification 21
to the Secretary under clause (i) shall in- 22
clude— 23
‘‘(I) a description of the number 24
of covered lives under the plan (or 25
328
O:AYOAYO08C32.xml S.L.C.
coverage) involved at the time of the 1
notification, and as applicable, at the 2
time of any prior election of the cost- 3
exemption under this paragraph by 4
such plan (or coverage); 5
‘‘(II) for both the plan year upon 6
which a cost exemption is sought and 7
the year prior, a description of the ac- 8
tual total costs of coverage with re- 9
spect to medical and surgical benefits 10
and mental health and substance use 11
disorder benefits under the plan; and 12
‘‘(III) for both the plan year 13
upon which a cost exemption is sought 14
and the year prior, the actual total 15
costs of coverage with respect to men- 16
tal health and substance use disorder 17
benefits under the plan. 18
‘‘(iii) CONFIDENTIALITY.—A notifica- 19
tion to the Secretary under clause (i) shall 20
be confidential. The Secretary shall make 21
available, upon request and on not more 22
than an annual basis, an anonymous 23
itemization of such notifications, that in- 24
cludes— 25
329
O:AYOAYO08C32.xml S.L.C.
‘‘(I) a breakdown of States by 1
the size and type of employers submit- 2
ting such notification; and 3
‘‘(II) a summary of the data re- 4
ceived under clause (ii). 5
‘‘(F) AUDITS BY APPROPRIATE AGEN- 6
CIES.—To determine compliance with this para- 7
graph, the Secretary may audit the books and 8
records of a group health plan or health insur- 9
ance issuer relating to an exemption, including 10
any actuarial reports prepared pursuant to sub- 11
paragraph (C), during the 6 year period fol- 12
lowing the notification of such exemption under 13
subparagraph (E). A State agency receiving a 14
notification under subparagraph (E) may also 15
conduct such an audit with respect to an ex- 16
emption covered by such notification.’’; 17
(4) in subsection (e), by striking paragraph (4) 18
and inserting the following: 19
‘‘(4) MENTAL HEALTH BENEFITS.—The term 20
‘mental health benefits’ means benefits with respect 21
to services for mental health conditions, as defined 22
under the terms of the plan and in accordance with 23
applicable Federal and State law. 24
330
O:AYOAYO08C32.xml S.L.C.
‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 1
The term ‘substance use disorder benefits’ means 2
benefits with respect to services for substance use 3
disorders, as defined under the terms of the plan 4
and in accordance with applicable Federal and State 5
law.’’; 6
(5) by striking subsection (f); 7
(6) by striking ‘‘mental health benefits’’ and in- 8
serting ‘‘mental health and substance use disorder 9
benefits’’ each place it appears in subsections 10
(a)(1)(B)(i), (a)(1)(C), (a)(2)(B)(i), and (a)(2)(C); 11
and 12
(7) by striking ‘‘mental health benefits’’ and in- 13
serting ‘‘mental health or substance use disorder 14
benefits’’ each place it appears (other than in any 15
provision amended by the previous paragraph). 16
(c) AMENDMENTS TO INTERNAL REVENUE CODE.— 17
Section 9812 of the Internal Revenue Code of 1986 is 18
amended— 19
(1) in subsection (a), by adding at the end the 20
following: 21
‘‘(3) FINANCIAL REQUIREMENTS AND TREAT- 22
MENT LIMITATIONS.— 23
‘‘(A) IN GENERAL.—In the case of a group 24
health plan that provides both medical and sur- 25
331
O:AYOAYO08C32.xml S.L.C.
gical benefits and mental health or substance 1
use disorder benefits, such plan shall ensure 2
that— 3
‘‘(i) the financial requirements appli- 4
cable to such mental health or substance 5
use disorder benefits are no more restric- 6
tive than the predominant financial re- 7
quirements applied to substantially all 8
medical and surgical benefits covered by 9
the plan, and there are no separate cost 10
sharing requirements that are applicable 11
only with respect to mental health or sub- 12
stance use disorder benefits; and 13
‘‘(ii) the treatment limitations applica- 14
ble to such mental health or substance use 15
disorder benefits are no more restrictive 16
than the predominant treatment limita- 17
tions applied to substantially all medical 18
and surgical benefits covered by the plan 19
and there are no separate treatment limi- 20
tations that are applicable only with re- 21
spect to mental health or substance use 22
disorder benefits. 23
‘‘(B) DEFINITIONS.—In this paragraph: 24
332
O:AYOAYO08C32.xml S.L.C.
‘‘(i) FINANCIAL REQUIREMENT.—The 1
term ‘financial requirement’ includes 2
deductibles, copayments, coinsurance, and 3
out-of-pocket expenses, but excludes an ag- 4
gregate lifetime limit and an annual limit 5
subject to paragraphs (1) and (2), 6
‘‘(ii) PREDOMINANT.—A financial re- 7
quirement or treatment limit is considered 8
to be predominant if it is the most com- 9
mon or frequent of such type of limit or 10
requirement. 11
‘‘(iii) TREATMENT LIMITATION.—The 12
term ‘treatment limitation’ includes limits 13
on the frequency of treatment, number of 14
visits, days of coverage, or other similar 15
limits on the scope or duration of treat- 16
ment. 17
‘‘(4) AVAILABILITY OF PLAN INFORMATION.— 18
The criteria for medical necessity determinations 19
made under the plan with respect to mental health 20
or substance use disorder benefits shall be made 21
available by the plan administrator in accordance 22
with regulations to any current or potential partici- 23
pant, beneficiary, or contracting provider upon re- 24
quest. The reason for any denial under the plan of 25
333
O:AYOAYO08C32.xml S.L.C.
reimbursement or payment for services with respect 1
to mental health or substance use disorder benefits 2
in the case of any participant or beneficiary shall, on 3
request or as otherwise required, be made available 4
by the plan administrator to the participant or bene- 5
ficiary in accordance with regulations. 6
‘‘(5) OUT-OF-NETWORK PROVIDERS.—In the 7
case of a plan that provides both medical and sur- 8
gical benefits and mental health or substance use 9
disorder benefits, if the plan provides coverage for 10
medical or surgical benefits provided by out-of-net- 11
work providers, the plan shall provide coverage for 12
mental health or substance use disorder benefits pro- 13
vided by out-of-network providers in a manner that 14
is consistent with the requirements of this section.’’; 15
(2) in subsection (b), by amending paragraph 16
(2) to read as follows: 17
‘‘(2) in the case of a group health plan that 18
provides mental health or substance use disorder 19
benefits, as affecting the terms and conditions of the 20
plan relating to such benefits under the plan, except 21
as provided in subsection (a).’’; 22
(3) in subsection (c)— 23
(A) by amending paragraph (1) to read as 24
follows: 25
334
O:AYOAYO08C32.xml S.L.C.
‘‘(1) SMALL EMPLOYER EXEMPTION.— 1
‘‘(A) IN GENERAL.—This section shall not 2
apply to any group health plan for any plan 3
year of a small employer. 4
‘‘(B) SMALL EMPLOYER.—For purposes of 5
subparagraph (A), the term ‘small employer’ 6
means, with respect to a calendar year and a 7
plan year, an employer who employed an aver- 8
age of at least 2 (or 1 in the case of an em- 9
ployer residing in a State that permits small 10
groups to include a single individual) but not 11
more than 50 employees on business days dur- 12
ing the preceding calendar year. For purposes 13
of the preceding sentence, all persons treated as 14
a single employer under subsection (b), (c), 15
(m), or (o) of section 414 shall be treated as 1 16
employer and rules similar to rules of subpara- 17
graphs (B) and (C) of section 4980D(d)(2) 18
shall apply.’’; and 19
(B) by striking paragraph (2) and insert- 20
ing the following: 21
‘‘(2) COST EXEMPTION.— 22
‘‘(A) IN GENERAL.—With respect to a 23
group health plan, if the application of this sec- 24
tion to such plan results in an increase for the 25
335
O:AYOAYO08C32.xml S.L.C.
plan year involved of the actual total costs of 1
coverage with respect to medical and surgical 2
benefits and mental health and substance use 3
disorder benefits under the plan (as determined 4
and certified under subparagraph (C)) by an 5
amount that exceeds the applicable percentage 6
described in subparagraph (B) of the actual 7
total plan costs, the provisions of this section 8
shall not apply to such plan during the fol- 9
lowing plan year, and such exemption shall 10
apply to the plan for 1 plan year. An employer 11
may elect to continue to apply mental health 12
and substance use disorder parity pursuant to 13
this section with respect to the group health 14
plan involved regardless of any increase in total 15
costs. 16
‘‘(B) APPLICABLE PERCENTAGE.—With re- 17
spect to a plan, the applicable percentage de- 18
scribed in this subparagraph shall be— 19
‘‘(i) 2 percent in the case of the first 20
plan year in which this section is applied; 21
and 22
‘‘(ii) 1 percent in the case of each 23
subsequent plan year. 24
336
O:AYOAYO08C32.xml S.L.C.
‘‘(C) DETERMINATIONS BY ACTUARIES.— 1
Determinations as to increases in actual costs 2
under a plan for purposes of this section shall 3
be made and certified by a qualified and li- 4
censed actuary who is a member in good stand- 5
ing of the American Academy of Actuaries. All 6
such determinations shall be in a written report 7
prepared by the actuary. The report, and all 8
underlying documentation relied upon by the 9
actuary, shall be maintained by the group 10
health plan for a period of 6 years following the 11
notification made under subparagraph (E). 12
‘‘(D) 6-MONTH DETERMINATIONS.—If a 13
group health plan seeks an exemption under 14
this paragraph, determinations under subpara- 15
graph (A) shall be made after such plan has 16
complied with this section for the first 6 17
months of the plan year involved. 18
‘‘(E) NOTIFICATION.— 19
‘‘(i) IN GENERAL.—A group health 20
plan that, based upon a certification de- 21
scribed under subparagraph (C), qualifies 22
for an exemption under this paragraph, 23
and elects to implement the exemption, 24
shall promptly notify the Secretary, the ap- 25
337
O:AYOAYO08C32.xml S.L.C.
propriate State agencies, and participants 1
and beneficiaries in the plan of such elec- 2
tion. 3
‘‘(ii) REQUIREMENT.—A notification 4
to the Secretary under clause (i) shall in- 5
clude— 6
‘‘(I) a description of the number 7
of covered lives under the plan in- 8
volved at the time of the notification, 9
and as applicable, at the time of any 10
prior election of the cost-exemption 11
under this paragraph by such plan; 12
‘‘(II) for both the plan year upon 13
which a cost exemption is sought and 14
the year prior, a description of the ac- 15
tual total costs of coverage with re- 16
spect to medical and surgical benefits 17
and mental health and substance use 18
disorder benefits under the plan; and 19
‘‘(III) for both the plan year 20
upon which a cost exemption is sought 21
and the year prior, the actual total 22
costs of coverage with respect to men- 23
tal health and substance use disorder 24
benefits under the plan. 25
338
O:AYOAYO08C32.xml S.L.C.
‘‘(iii) CONFIDENTIALITY.—A notifica- 1
tion to the Secretary under clause (i) shall 2
be confidential. The Secretary shall make 3
available, upon request and on not more 4
than an annual basis, an anonymous 5
itemization of such notifications, that in- 6
cludes— 7
‘‘(I) a breakdown of States by 8
the size and type of employers submit- 9
ting such notification; and 10
‘‘(II) a summary of the data re- 11
ceived under clause (ii). 12
‘‘(F) AUDITS BY APPROPRIATE AGEN- 13
CIES.—To determine compliance with this para- 14
graph, the Secretary may audit the books and 15
records of a group health plan relating to an 16
exemption, including any actuarial reports pre- 17
pared pursuant to subparagraph (C), during 18
the 6 year period following the notification of 19
such exemption under subparagraph (E). A 20
State agency receiving a notification under sub- 21
paragraph (E) may also conduct such an audit 22
with respect to an exemption covered by such 23
notification.’’; 24
339
O:AYOAYO08C32.xml S.L.C.
(4) in subsection (e), by striking paragraph (4) 1
and inserting the following: 2
‘‘(4) MENTAL HEALTH BENEFITS.—The term 3
‘mental health benefits’ means benefits with respect 4
to services for mental health conditions, as defined 5
under the terms of the plan and in accordance with 6
applicable Federal and State law. 7
‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 8
The term ‘substance use disorder benefits’ means 9
benefits with respect to services for substance use 10
disorders, as defined under the terms of the plan 11
and in accordance with applicable Federal and State 12
law.’’; 13
(5) by striking subsection (f); 14
(6) by striking ‘‘mental health benefits’’ and in- 15
serting ‘‘mental health and substance use disorder 16
benefits’’ each place it appears in subsections 17
(a)(1)(B)(i), (a)(1)(C), (a)(2)(B)(i), and (a)(2)(C); 18
and 19
(7) by striking ‘‘mental health benefits’’ and in- 20
serting ‘‘mental health or substance use disorder 21
benefits’’ each place it appears (other than in any 22
provision amended by the previous paragraph). 23
(d) REGULATIONS.—Not later than 1 year after the 24
date of enactment of this Act, the Secretaries of Labor, 25
340
O:AYOAYO08C32.xml S.L.C.
Health and Human Services, and the Treasury shall issue 1
regulations to carry out the amendments made by sub- 2
sections (a), (b), and (c), respectively. 3
(e) EFFECTIVE DATE.— 4
(1) IN GENERAL.—The amendments made by 5
this section shall apply with respect to group health 6
plans for plan years beginning after the date that is 7
1 year after the date of enactment of this Act, re- 8
gardless of whether regulations have been issued to 9
carry out such amendments by such effective date, 10
except that the amendments made by subsections 11
(a)(5), (b)(5), and (c)(5), relating to striking of cer- 12
tain sunset provisions, shall take effect on January 13
1, 2009. 14
(2) SPECIAL RULE FOR COLLECTIVE BAR- 15
GAINING AGREEMENTS.—In the case of a group 16
health plan maintained pursuant to one or more col- 17
lective bargaining agreements between employee rep- 18
resentatives and one or more employers ratified be- 19
fore the date of the enactment of this Act, the 20
amendments made by this section shall not apply to 21
plan years beginning before the later of— 22
(A) the date on which the last of the col- 23
lective bargaining agreements relating to the 24
plan terminates (determined without regard to 25
341
O:AYOAYO08C32.xml S.L.C.
any extension thereof agreed to after the date 1
of the enactment of this Act), or 2
(B) January 1, 2009. 3
For purposes of subparagraph (A), any plan amend- 4
ment made pursuant to a collective bargaining 5
agreement relating to the plan which amends the 6
plan solely to conform to any requirement added by 7
this section shall not be treated as a termination of 8
such collective bargaining agreement. 9
(f) ASSURING COORDINATION.—The Secretary of 10
Health and Human Services, the Secretary of Labor, and 11
the Secretary of the Treasury may ensure, through the 12
execution or revision of an interagency memorandum of 13
understanding among such Secretaries, that— 14
(1) regulations, rulings, and interpretations 15
issued by such Secretaries relating to the same mat- 16
ter over which two or more such Secretaries have re- 17
sponsibility under this section (and the amendments 18
made by this section) are administered so as to have 19
the same effect at all times; and 20
(2) coordination of policies relating to enforcing 21
the same requirements through such Secretaries in 22
order to have a coordinated enforcement strategy 23
that avoids duplication of enforcement efforts and 24
assigns priorities in enforcement. 25
342
O:AYOAYO08C32.xml S.L.C.
(g) CONFORMING CLERICAL AMENDMENTS.— 1
(1) ERISA HEADING.— 2
(A) IN GENERAL.—The heading of section 3
712 of the Employee Retirement Income Secu- 4
rity Act of 1974 is amended to read as follows: 5
‘‘SEC. 712. PARITY IN MENTAL HEALTH AND SUBSTANCE 6
USE DISORDER BENEFITS.’’. 7
(B) CLERICAL AMENDMENT.—The table of 8
contents in section 1 of such Act is amended by 9
striking the item relating to section 712 and in- 10
serting the following new item: 11
‘‘Sec. 712. Parity in mental health and substance use disorder benefits.’’.
(2) PHSA HEADING.—The heading of section 12
2705 of the Public Health Service Act is amended 13
to read as follows: 14
‘‘SEC. 2705. PARITY IN MENTAL HEALTH AND SUBSTANCE 15
USE DISORDER BENEFITS.’’. 16
(3) IRC HEADING.— 17
(A) IN GENERAL.—The heading of section 18
9812 of the Internal Revenue Code of 1986 is 19
amended to read as follows: 20
‘‘SEC. 9812. PARITY IN MENTAL HEALTH AND SUBSTANCE 21
USE DISORDER BENEFITS.’’. 22
(B) CLERICAL AMENDMENT.—The table of 23
sections for subchapter B of chapter 100 of 24
such Code is amended by striking the item re- 25
343
O:AYOAYO08C32.xml S.L.C.
lating to section 9812 and inserting the fol- 1
lowing new item: 2
‘‘Sec. 9812. Parity in mental health and substance use disorder benefits.’’.
(h) GAO STUDY ON COVERAGE AND EXCLUSION OF 3
MENTAL HEALTH AND SUBSTANCE USE DISORDER DIAG- 4
NOSES.— 5
(1) IN GENERAL.—The Comptroller General of 6
the United States shall conduct a study that ana- 7
lyzes the specific rates, patterns, and trends in cov- 8
erage and exclusion of specific mental health and 9
substance use disorder diagnoses by health plans 10
and health insurance. The study shall include an 11
analysis of— 12
(A) specific coverage rates for all mental 13
health conditions and substance use disorders; 14
(B) which diagnoses are most commonly 15
covered or excluded; 16
(C) whether implementation of this Act 17
has affected trends in coverage or exclusion of 18
such diagnoses; and 19
(D) the impact of covering or excluding 20
specific diagnoses on participants’ and enroll- 21
ees’ health, their health care coverage, and the 22
costs of delivering health care. 23
(2) REPORTS.—Not later than 3 years after the 24
date of the enactment of this Act, and 2 years after 25
344
O:AYOAYO08C32.xml S.L.C.
the date of submission the first report under this 1
paragraph, the Comptroller General shall submit to 2
Congress a report on the results of the study con- 3
ducted under paragraph (1).
from
[link to www.foxnews.com] |
| Anonymous Coward
User ID: 483150
10/1/2008 11:17 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
it fucking doesn't even make sense, its like a computer randomly put some words together  |
| Anonymous Coward
User ID: 490625 (OP)
10/1/2008 11:20 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
well, this is part of the bailout bill
why so much on the mental health & substance abuse part?
there must be something important about it
what about this part?
‘‘(4) AVAILABILITY OF PLAN INFORMATION.— 7
The criteria for medical necessity determinations 8
made under the plan with respect to mental health 9
or substance use disorder benefits (or the health in- 10
surance coverage offered in connection with the plan 11
with respect to such benefits) shall be made avail- 12
able by the plan administrator (or the health insur- 13
ance issuer offering such coverage) in accordance 14
with regulations to any current or potential partici- 15
pant, beneficiary, or contracting provider upon re- 16
quest. The reason for any denial under the plan (or 17
coverage) of reimbursement or payment for services 18
with respect to mental health or substance use dis- 19
order benefits in the case of any participant or bene- 20
ficiary shall, on request or as otherwise required, be 21
made available by the plan administrator (or the 22
health insurance issuer offering such coverage) to 23
the participant or beneficiary in accordance with 24
regulations. 25 |
| Anonymous Coward
User ID: 513803
10/1/2008 11:25 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
I was told today that it basically says that the insurance companies have to start treating "mental" conditions the same as "physical" conditions as far as insurance issues go |
| the illusionist
User ID: 437387
10/1/2008 11:25 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
It means Harlow's monkey's are hungry for Dr Tar's professional feather.
It means you're all crazy and first into the camps.
[link to www.godlikeproductions.com]
And the corporafasci's torturers and profilers will know it before the sicko does.
All except StrugholdStraggler's cognitive dissonance NWO kapos, who will not only survive but thrive as sadistic slave torturing psychos.
It means Buddha was right. All is illusion. |
| Anonymous Coward
User ID: 490625 (OP)
10/1/2008 11:29 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
I was told today that it basically says that the insurance companies have to start treating "mental" conditions the same as "physical" conditions as far as insurance issues go Quoting: Anonymous Coward 513803
hmm, then why did it take so many words to say that? they could have just said what you just said and saved some paper
i think there must be more between the lines |
| Anonymous Coward
User ID: 490625 (OP)
10/1/2008 11:30 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
It means Harlow's monkey's are hungry for Dr Tar's professional feather.
It means you're all crazy and first into the camps.
[ link to www.godlikeproductions.com]
And the corporafasci's torturers and profilers will know it before the sicko does.
All except StrugholdStraggler's cognitive dissonance NWO kapos, who will not only survive but thrive as sadistic slave torturing psychos.
It means Buddha was right. All is illusion.
hmm, that's what i was afraid it might mean |
| Anonymous Coward
User ID: 510528
10/1/2008 11:31 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
It means most American GLPers will have the same coverage as other conditions... |
| Anonymous Coward
User ID: 513803
10/1/2008 11:31 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
I was told today that it basically says that the insurance companies have to start treating "mental" conditions the same as "physical" conditions as far as insurance issues go
hmm, then why did it take so many words to say that? they could have just said what you just said and saved some paper
i think there must be more between the lines Quoting: Anonymous Coward 490625
There usually is............
 |
| new freedom
User ID: 437387
10/1/2008 11:36 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
Harlow's rack would sooner lobotomize than fix the source of the OCD ritual psychosis.
 |
| Anonymous Coward
User ID: 490625 (OP)
10/1/2008 11:37 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
It means most American GLPers will have the same coverage as other conditions... Quoting: Anonymous Coward 510528
but will they be at the top of the 'list'? |
| Anonymous Coward
User ID: 490625 (OP)
10/1/2008 11:42 PM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
Harlow's rack would sooner lobotomize than fix the source of the OCD ritual psychosis.
‘‘(iii) TREATMENT LIMITATION.—The 12
term ‘treatment limitation’ includes limits 13
on the frequency of treatment, number of 14
visits, days of coverage, or other similar 15
limits on the scope or duration of treat- 16
ment. 17 |
| reader1
User ID: 407257
10/2/2008 12:11 AM | | Re: SEC. 512. Mental Health Parity (Can someone translate what this means?) | Quote |
it means that your premium for physical problems will go
up, your coverage will go down and less people will get
insurance as it will become less affordable. Anyway it is not going to pass, I can see the medical insurance's executives working the whole night in order to block the bill, thank you God. |
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