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House Report 110-374 Part 1

House Report 110-374 Part 1

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Published by Tax History
Legislative history of the Paul Wellstone Mental Health and Addiction Equity Act, which became part of the Emergency Economic Stabilization Act of 2008 (PL 110-343), aka second Bush stimulus.
Legislative history of the Paul Wellstone Mental Health and Addiction Equity Act, which became part of the Emergency Economic Stabilization Act of 2008 (PL 110-343), aka second Bush stimulus.

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Published by: Tax History on Dec 30, 2009
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01/15/2013

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69–006
110
TH
C
ONGRESS
R
EPT
. 110–374
 " !
HOUSE OF REPRESENTATIVES
1st Session
Part 1
PAUL WELLSTONE MENTAL HEALTH AND ADDICTIONEQUITY ACT OF 2007
O
CTOBER
15, 2007.—Ordered to be printed
Mr. G
EORGE
M
ILLER
of California, from the Committee onEducation and Labor, submitted the following
R E P O R T
together withMINORITY VIEWS
[To accompany H.R. 1424][Including cost estimate of the Congressional Budget Office]
The Committee on Education and Labor, to whom was referredthe bill (H.R. 1424) to amend section 712 of the Employee Retire-ment Income Security Act of 1974, section 2705 of the PublicHealth Service Act, and section 9812 of the Internal Revenue Codeof 1986 to require equity in the provision of mental health and sub-stance-related disorder benefits under group health plans, havingconsidered the same, report favorably thereon with an amendmentand recommend that the bill as amended do pass.The amendment is as follows:Strike all after the enacting clause and insert the following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) S
HORT
T
ITLE
.—This Act may be cited as the ‘‘Paul Wellstone Mental Healthand Addiction Equity Act of 2007’’.(b) T
 ABLE OF
C
ONTENTS
.—The table of contents of this Act is as follows:
Sec.1.Short title; table of contents.Sec.2.Amendments to the Employee Retirement Income Security Act of 1974.Sec.3.Amendments to the Public Health Service Act relating to the group market.Sec.5.Amendments to the Internal Revenue Code of 1986.Sec.5.Government Accountability Office studies and reports.
SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) E
 XTENSION OF
P
 ARITY TO
T
REATMENT
L
IMITS AND
B
ENEFICIARY
F
INANCIAL
R
E
-
QUIREMENTS
.—Section 712 of the Employee Retirement Income Security Act of 1974(29 U.S.C. 1185a) is amended—
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2
(1) in subsection (a), by adding at the end the following new paragraphs:
‘‘
(3) T
REATMENT LIMITS
.
 
‘‘
(A) N
O TREATMENT LIMIT
.
If the plan or coverage does not include atreatment limit (as defined in subparagraph (D)) on substantially all med-ical and surgical benefits in any category of items or services, the plan orcoverage may not impose any treatment limit on mental health or sub-stance-related disorder benefits that are classified in the same category of items or services.
‘‘
(B) T
REATMENT LIMIT
.
If the plan or coverage includes a treatmentlimit on substantially all medical and surgical benefits in any category of items or services, the plan or coverage may not impose such a treatmentlimit on mental health or substance-related disorder benefits for items andservices within such category that is more restrictive than the predominanttreatment limit that is applicable to medical and surgical benefits for itemsand services within such category.
‘‘
(C) C
 ATEGORIES OF ITEMS AND SERVICES FOR APPLICATION OF TREATMENT
 
LIMITS AND BENEFICIARY FINANCIAL REQUIREMENTS
.
For purposes of thisparagraph and paragraph (4), there shall be the following five categories of items and services for benefits, whether medical and surgical benefits ormental health and substance-related disorder benefits, and all medical andsurgical benefits and all mental health and substance related benefits shallbe classified into one of the following categories:
‘‘
(i) I
NPATIENT
,
IN
-
NETWORK 
.
Items and services not described inclause (v) furnished on an inpatient basis and within a network of pro-viders established or recognized under such plan or coverage.
‘‘
(ii) I
NPATIENT
,
OUT
-
OF
-
NETWORK 
.
Items and services not describedin clause (v) furnished on an inpatient basis and outside any networkof providers established or recognized under such plan or coverage.
‘‘
(iii) O
UTPATIENT
,
IN
-
NETWORK 
.
Items and services not described inclause (v) furnished on an outpatient basis and within a network of providers established or recognized under such plan or coverage.
‘‘
(iv) O
UTPATIENT
,
OUT
-
OF
-
NETWORK 
.
Items and services not de-scribed in clause (v) furnished on an outpatient basis and outside anynetwork of providers established or recognized under such plan or cov-erage.
‘‘
(v) E
MERGENCY CARE
.
Items and services, whether furnished on aninpatient or outpatient basis or within or outside any network of pro-viders, required for the treatment of an emergency medical condition(including an emergency condition relating to mental health and sub-stance-related disorders).
‘‘
(D) T
REATMENT LIMIT DEFINED
.
For purposes of this paragraph, theterm
treatment limit
means, with respect to a plan or coverage, limitationon the frequency of treatment, number of visits or days of coverage, or othersimilar limit on the duration or scope of treatment under the plan or cov-erage.
‘‘
(E) P
REDOMINANCE
.
For purposes of this subsection, a treatment limitor financial requirement with respect to a category of items and services isconsidered to be predominant if it is the most common or frequent of suchtype of limit or requirement with respect to such category of items andservices.
‘‘
(4) B
ENEFICIARY FINANCIAL REQUIREMENTS
.
 
‘‘
(A) N
O BENEFICIARY FINANCIAL REQUIREMENT
.
If the plan or coveragedoes not include a beneficiary financial requirement (as defined in subpara-graph (C)) on substantially all medical and surgical benefits within a cat-egory of items and services (specified under paragraph (3)(C)), the plan orcoverage may not impose such a beneficiary financial requirement on men-tal health or substance-related disorder benefits for items and serviceswithin such category.
‘‘
(B) B
ENEFICIARY FINANCIAL REQUIREMENT
.
 
‘‘
(i) T
REATMENT OF DEDUCTIBLES
,
OUT
-
OF
-
POCKET LIMITS
,
 AND SIMILAR
 
FINANCIAL REQUIREMENTS
.
If the plan or coverage includes a deduct-ible, a limitation on out-of-pocket expenses, or similar beneficiary finan-cial requirement that does not apply separately to individual items andservices on substantially all medical and surgical benefits within a cat-egory of items and services (as specified in paragraph (3)(C)), the planor coverage shall apply such requirement (or, if there is more than onesuch requirement for such category of items and services, the predomi-nant requirement for such category) both to medical and surgical bene-fits within such category and to mental health and substance-related
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3
disorder benefits within such category and shall not distinguish in theapplication of such requirement between such medical and surgicalbenefits and such mental health and substance-related disorder bene-fits.
‘‘
(ii) O
THER FINANCIAL REQUIREMENTS
.
If the plan or coverage in-cludes a beneficiary financial requirement not described in clause (i) onsubstantially all medical and surgical benefits within a category of items and services, the plan or coverage may not impose such financialrequirement on mental health or substance-related disorder benefits foritems and services within such category in a way that results in greaterout-of-pocket expenses to the participant or beneficiary than the pre-dominant beneficiary financial requirement applicable to medical andsurgical benefits for items and services within such category.
‘‘
(iii) C
ONSTRUCTION
.
Nothing in this subparagraph shall be con-strued as prohibiting the plan or coverage from waiving the applicationof any deductible for mental health benefits or substance-related dis-order benefits or both.
‘‘
(C) B
ENEFICIARY FINANCIAL REQUIREMENT DEFINED
.
For purposes of this paragraph, the term
beneficiary financial requirement
includes, withrespect to a plan or coverage, any deductible, coinsurance, co-payment,other cost sharing, and limitation on the total amount that may be paid bya participant or beneficiary with respect to benefits under the plan or cov-erage, but does not include the application of any aggregate lifetime limitor annual limit.
’’
; and(2) in subsection (b)
 (A) by striking
‘‘
construed
—’’
and all that follows through
‘‘
(1) as requir-ing
’’
and inserting
‘‘
construed as requiring
’’
;(B) by striking
‘‘
; or
’’
and inserting a period; and(C) by striking paragraph (2).(b) E
 XPANSION TO
S
UBSTANCE
-R
ELATED
D
ISORDER
B
ENEFITS AND
R
EVISION OF
 D
EFINITION
.
Such section is further amended
 (1) by striking
‘‘
mental health benefits
’’
and inserting
‘‘
mental health or sub-stance-related disorder benefits
’’
each place it appears; and(2) in paragraph (4) of subsection (e)
 (A) by striking
‘‘
M
ENTAL HEALTH BENEFITS
’’
and inserting
‘‘
M
ENTAL
 
HEALTH AND SUBSTANCE
-
RELATED DISORDER BENEFITS
’’
;(B) by striking
‘‘
benefits with respect to mental health services
’’
and in-serting
‘‘
benefits with respect to services for mental health conditions orsubstance-related disorders
’’
; and(C) by striking
‘‘
, but does not include benefits with respect to treatmentof substance abuse or chemical dependency
’’
.(c) A
 VAILABILITY OF
P
LAN
I
NFORMATION
 A
BOUT
C
RITERIA FOR
M
EDICAL
N
ECES
-
SITY
.
Subsection (a) of such section, as amended by subsection (a)(1), is furtheramended by adding at the end the following new paragraph:
‘‘
(5) A
 VAILABILITY OF PLAN INFORMATION
.
The criteria for medical necessitydeterminations made under the plan with respect to mental health and sub-stance-related disorder benefits (or the health insurance coverage offered in con-nection with the plan with respect to such benefits) shall be made available inaccordance with regulations by the plan administrator (or the health insuranceissuer offering such coverage) to any current or potential participant, bene-ficiary, or contracting provider upon request. The reason for any denial underthe plan (or coverage) of reimbursement or payment for services with respectto mental health and substance-related disorder benefits in the case of any par-ticipant or beneficiary shall, upon request, be made available in accordance withregulations by the plan administrator (or the health insurance issuer offeringsuch coverage) to the participant or beneficiary.
’’
.(d) M
INIMUM
B
ENEFIT
R
EQUIREMENTS
.
Subsection (a) of such section is furtheramended by adding at the end the following new paragraph:
‘‘
(6) M
INIMUM SCOPE OF COVERAGE AND EQUITY IN OUT
-
OF
-
NETWORK BENE
-
FITS
.
 
‘‘
(A) M
INIMUM SCOPE OF MENTAL HEALTH AND SUBSTANCE
-
RELATED DIS
-
ORDER BENEFITS
.
In the case of a group health plan (or health insurancecoverage offered in connection with such a plan) that provides any mentalhealth or substance-related disorder benefits, the plan or coverage shall in-clude benefits for any mental health condition and substance-related dis-order for which benefits are provided under the benefit plan option offeredunder chapter 89 of title 5, United States Code, with the highest averageenrollment as of the beginning of the most recent year beginning on or be-fore the beginning of the plan year involved.
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