Short title; table of contents

(a)

Short title

This Act may be cited as the

Behavioral Health Network and Directory Improvement Act

.(b)

Table of contents

The table of contents for this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Protecting patients and improving the accuracy of provider directory information.

Sec. 3. Provider requirements to protect patients and improve the accuracy of provider directory information.

Sec. 4. Strengthening mental health and substance use disorder parity requirements.

Sec. 5. State and Tribal ombudsman programs relating to mental health and substance use disorder parity.

Sec. 6. Report to Congress.

Sec. 7. Authorization of appropriations.

Protecting patients and improving the accuracy of provider directory information

(a)

PHSA

Section 2799A–5 of the Public Health Service Act (42 U.S.C. 300gg–115) is amended—(1)in subsection (a)—(A)in paragraph (1)—(i)by striking For plan years beginning on or after January 1, 2022, each and inserting Each; (ii)in subparagraph (C), by striking ; and and inserting a semicolon;(iii)in subparagraph (D), by striking the period and inserting ; and; and(iv)by adding at the end the following:

(E)ensure that any directory, including the database described in subparagraph (C), containing provider directory information with respect to such plan or such coverage complies with the requirements developed by the appropriate agencies in accordance with paragraph (6) in order to ensure that participants, beneficiaries, and enrollees are able to identify actively participating health care providers and health care facilities.

;

(B)in paragraph (3)—(i)in the matter preceding subparagraph (A), by striking , in the case such request is made through a telephone call; and(ii)in subparagraph (A), by striking call is received, through a written electronic or print (as requested by such individual) communication and inserting a request is received, by telephone, or through a written electronic or print communication (as requested by such individual);(C)in paragraph (4)—(i)in subparagraph (A), by striking and at the end;(ii)in subparagraph (B), by striking the period and inserting ; and; and(iii)by adding at the end the following:

(C)information, in plain language, concerning the rights of the participant, beneficiary, or enrollee to cost-sharing protections pursuant to subsection (b) in the event of reliance on inaccurate provider network information supplied by a group health plan or health insurance issuer, and contact information for, as appropriate, the State consumer assistance program or ombudsman or the Employee Benefits Security Administration for more information.

;

(D)in paragraph (5), by adding at the end the following: Such information shall include a statement, in plain language, concerning the rights of the participant, beneficiary, or enrollee to cost-sharing protections pursuant to subsection (b) in the event of reliance on inaccurate provider directory information supplied by a group health plan or health insurance issuer, and contact information for, as appropriate, the State consumer assistance program or ombudsman or the Employee Benefits Security Administration for more information.;(E)by redesignating paragraphs (6) and (7) as paragraphs (8) and (9), respectively; (F)by inserting after paragraph (5) the following:

(6)

Protecting participants, beneficiaries, and enrollees from ghost networks

The Secretary, in collaboration with the Secretary of Labor and the Secretary of the Treasury, shall—(A)not later than 4 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, issue final regulations further defining the term ghost network (as defined in paragraph (8)); and(B)not later than 4 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, issue final regulations, subregulatory guidance, or program instruction on how to assess ghost networks in health plan directories including reasonable assumptions related to statistics and research methods.(7)

Database reporting and auditing to protect against ghost networks

(A)

Reporting requirements

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan and health insurance issuer offering group or individual health insurance coverage shall submit to the Secretary, at such time as the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall require, but not less frequently than annually, the directory data described in paragraph (a)(4), in a machine readable format (as defined in section 147.210(a)(2)(xiv) of title 45, Code of Federal Regulations (or any successor regulations)). A health insurance issuer or a third party administrator of a group health plan may submit such information for all health insurance coverage or all group health plans, collectively, that such issuer or administrator administers. The Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall make data submitted under this subparagraph available on a public website.(B)

Provider directory independent audit requirements

(i)

In general

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan and health insurance issuer offering group or individual health insurance coverage shall conduct an annual directory audit, through an independent entity not associated with the health plan or issuer, that considers the factors described in clause (ii)(I)(aa) and follows the guidelines developed under clause (ii)(I)(bb).(ii)

Information to be included

(I)

In general

For purposes of carrying out the audits under this subparagraph, the Secretary shall—(aa)develop a list of information required to be included; and(bb)provide guidelines for carrying out such audits, for use by group health plans and health insurance issuers, on—(AA)the reasonable assumptions and research methods to select a reasonable sample in order to assess provider directory information accuracy; and (BB)determining the criteria of an eligible auditor. (II)

Contents

The information listed under subclause (I)(aa) shall include the following:(aa)The proportion of directory listings of the plan or coverage with inaccurate information, including incorrect contact information, as specified by the Secretary, during the audit period.(bb)The number of in-network items or services paid on behalf of participants, beneficiaries, and enrollees in the plan or coverage to providers or facilities who have a network provider contract with the health plan or issuer and were not listed in the directory of the health plan or health insurance coverage for the audit period. (cc)The resources of the plan or issuer to help participants, beneficiaries, and enrollees locate an accurately listed in-network provider who is accepting new patients.(dd)The proportion of participants, beneficiaries, and enrollees using out-of-network providers for mental health and substance use disorder services, and the proportion of participants, beneficiaries, and enrollees using out-of-network providers and facilities for medical and surgical services.(ee)Documentation that the plan or issuer verifies the accuracy of the provider directory information every 90 days.(ff)Other factors as determined by the Secretary.(iii)

Standards for reporting

An audit under this subparagraph is complete if all of the following conditions are met: (I) The audit report includes the following:(aa)A statement by the independent auditor that, to the best of the auditor's knowledge, the report is complete and accurate, and that reasonable assumptions related to statistics and research methods have been complied with.(bb)A statement explaining the assumptions, statistics, and methods used to select the sample and assess provider directory information accuracy.(cc)Such other requirements as the Secretary determines necessary.(II)The group health plan or health insurer issuer makes the independent audit available on a public website.(iv)

Rulemaking

The Secretary, the Secretary of Labor, and the Secretary of the Treasury shall issue interim final regulations (without prior notice and comment as generally required under section 553 of title 5, United States Code) concerning the national standards for conducting audits under this subparagraph, not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act.(C)

Audits by the Secretary

(i)

In general

Beginning not later than the fourth plan year after the date of enactment of the Behavioral Health Network and Directory Improvement Act, the Secretary shall conduct annual audits to ensure compliance with the auditing requirements under subparagraph (B). (ii)

Selection of plans and issuers

The Secretary, the Secretary of Labor, and the Secretary of the Treasury (referred to in this clause as the Secretaries), jointly, shall conduct annual audits of the submissions under subparagraph (B) of a total of not fewer than 10 group health plans or health insurance issuers offering group or individual health insurance coverage, as determined by the Secretaries, that are the subjects of complaints about ghost networks or other complaints, or that are randomly selected by the Secretaries.

; and

(G)in paragraph (8), as so redesignated—(i)in the paragraph heading, by striking

Definition

and inserting

Definitions

;(ii)by striking For purposes of this subsection, the term and inserting the following: “For purposes of this subsection:

(A)

Provider directory information

The term

;

(iii)by striking health insurance coverage, the name, address and inserting “health insurance coverage—

(i)the name, address where the provider regularly sees patients

;

(iv)by striking the period and inserting ; and; and(v)by adding at the end the following:

(ii)with respect to each such provider or facility—(I)whether such provider or facility is accepting new patients;(II)the languages spoken and the availability of language translators for specified languages at each health care facility listed in the directory;(III)whether the provider or facility offers medication-assisted treatment for opioid use disorder;(IV)the State license number;(V)the national provider identifier; (VI)the age groups served by the provider or facility, such as pediatric, adolescent, adult, or geriatric populations; (VII)whether such provider or facility offers in-person services, telehealth services, or both; (VIII)the cost-sharing tier, if applicable; and(IX)health insurance plans accepted (including the plan identifier and type of plan).(B)

Ghost network

The term ghost network means a group health plan or group or individual health insurance coverage for which the provider directory information describing the network of such plan or coverage—(i)includes inaccurate contact information with respect to a substantial share of included listings and providers who are part of the network; (ii)includes a substantial number of providers and facilities (as specified by the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury) in a specialty who are not accepting new patients within a time period specified by such secretaries;(iii)includes a substantial number of providers and facilities that are not part of the network; or(iv)omits a substantial number of providers and facilities that are part of the network.

; and

(2)in subsection (b)—(A)in paragraph (1), by striking and if either of the criteria described in paragraph (2) applies with respect to such participant, beneficiary, or enrollee and item or service; and(B)by striking paragraph (2) and inserting the following:

(2)

Reconciliation requirement

If a nonparticipating provider was listed as a participating provider in the posted provider directory database, the group health plan or health insurance issuer shall, not later than 30 days after receiving the request for payment, notify the participant, beneficiary, or enrollee, in plain language, that the participant, beneficiary, or enrollee may be eligible for a refund from the group health plan or health insurance issuer if such participant, beneficiary, or enrollee paid the out of network cost-sharing and did not receive a refund under section 2799B–9(b).

(b)

ERISA

(1)

In general

Section 720 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185i) is amended—(A)in subsection (a)—(i)in paragraph (1)—(I)by striking For plan years beginning on or after January 1, 2022, each and inserting Each; (II)in subparagraph (C), by striking ; and and inserting a semicolon;(III)in subparagraph (D), by striking the period and inserting ; and; and(IV)by adding at the end the following:

;

(ii)in paragraph (3)—(I)in the matter preceding subparagraph (A), by striking , in the case such request is made through a telephone call; and(II)in subparagraph (A), by striking call is received, through a written electronic or print (as requested by such individual) communication and inserting a request is received, by telephone, or through a written electronic or print communication (as requested by such individual);(iii)in paragraph (4)—(I)in subparagraph (A), by striking and at the end;(II)in subparagraph (B), by striking the period and inserting ; and; and(III)by adding at the end the following:

;

(iv)in paragraph (5), by adding at the end the following: Such information shall include a statement, in plain language, concerning the rights of the participant, beneficiary, or enrollee to cost-sharing protections pursuant to subsection (b) in the event of reliance on inaccurate provider directory information supplied by a group health plan or health insurance issuer, and contact information for, as appropriate, the State consumer assistance program or ombudsman or the Employee Benefits Security Administration for more information.;(v)by redesignating paragraphs (6) and (7) as paragraphs (8) and (9), respectively; (vi)by inserting after paragraph (5) the following:

(6)

Protecting participants, beneficiaries, and enrollees from ghost networks

Database reporting and auditing to protect against ghost networks

(A)

Reporting requirements

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan and health insurance issuer offering group health insurance coverage shall submit to the Secretary, at such time as the Secretary, in coordination with the Secretary of Health and Human Services and the Secretary of the Treasury, shall require, but not less frequently than annually, the directory data described in paragraph (a)(4), in a machine readable format (as defined in section 147.210(a)(2)(xiv) of title 45, Code of Federal Regulations (or any successor regulations)). A health insurance issuer or a third party administrator of a group health plan may submit such information for all health insurance coverage or all group health plans, collectively, that such issuer or administrator administers. The Secretary, in coordination with the Secretary of Health and Human Services and the Secretary of the Treasury, shall make data submitted under this subparagraph available on a public website.(B)

Provider directory independent audit requirements

(i)

In general

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan and health insurance issuer offering group health insurance coverage shall conduct an annual directory audit, through an independent entity not associated with the health plan or issuer, that considers the factors described in clause (ii)(I)(aa) and follows the guidelines developed under clause (ii)(I)(bb).(ii)

Information to be included

(I)

In general

Contents

Standards for reporting

Rulemaking

The Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury shall issue interim final regulations (without prior notice and comment as generally required under section 553 of title 5, United States Code) concerning the national standards for conducting audits under this subparagraph, not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act.(C)

Audits by the Secretary

(i)

In general

Selection of plans and issuers

The Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury (referred to in this clause as the Secretaries), jointly, shall conduct annual audits of the submissions under subparagraph (B) of a total of not fewer than 10 group health plans or health insurance issuers offering group health insurance coverage, as determined by the Secretaries, that are the subjects of complaints about ghost networks or other complaints, or that are randomly selected by the Secretaries.

; and

(vii)in paragraph (8), as so redesignated—(I)in the paragraph heading, by striking

Definition

and inserting

Definitions

;(II)by striking For purposes of this subsection, the term and inserting the following: “For purposes of this subsection:

(A)

Provider directory information

The term

;

(III)by striking health insurance coverage, the name, address and inserting “health insurance coverage—

(i)the name, address where the provider regularly sees patients

;

(IV)by striking the period and inserting ; and; and(V)by adding at the end the following:

Ghost network

The term ghost network means a group health plan or group health insurance coverage for which the provider directory information describing the network of such plan or coverage—(i)includes inaccurate contact information with respect to a substantial share of included listings and providers who are part of the network; (ii)includes a substantial number of providers and facilities (as specified by the Secretary, in coordination with the Secretary of Health and Human Services and the Secretary of the Treasury) in a specialty who are not accepting new patients within a time period specified by such secretaries;(iii)includes a substantial number of providers and facilities that are not part of the network; or(iv)omits a substantial number of providers and facilities that are part of the network.

; and

(B)in subsection (b)—(i)in paragraph (1), by striking and if either of the criteria described in paragraph (2) applies with respect to such participant, beneficiary, or enrollee and item or service; and(ii)by striking paragraph (2) and inserting the following:

(2)

Reconciliation requirement

(2)

Civil monetary penalties for violations

(A)

Civil monetary penalties relating to provider directory requirements

Section 502(c)(10) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1132(c)(10)(A)) is amended—(i) in the heading, by striking

use of genetic information

and inserting

use of genetic information and provider directory requirements

; and(ii) in subparagraph (A)—(I)by inserting plan administrator of a group health plan (including a third party administrator), after plan sponsor of a group health plan,; (II)by inserting , administrator, after such sponsor; and(III)by striking for any failure and all that follows through in connection with the plan. and inserting

for any failure by such plan sponsor, plan administrator, or health insurance issuer, in connection with the plan—(i)to meet the requirements of subsection (a)(1)(F), (b)(3), (c), or (d) of section 702 or section 701 or 702(b)(1) with respect to genetic information; or(ii)to meet the requirements of section 720 with respect to provider directory information.

(B)

Exception to the general prohibition on enforcement

Section 502 of such Act (29 U.S.C. 1132) is amended—(i)in subsection (a)(6), by striking or (9) and inserting (9), or (10); and(ii)in subsection (b)(3)—(I)by striking subsections (c)(9) and (a)(6) and inserting subsections (c)(9), (c)(10), and (a)(6);(II)by striking under subsection (c)(9)) and inserting under subsections (c)(9) and (c)(10)), and except with respect to enforcement by the Secretary of section 720; and(III)by striking 706(a)(1) and inserting 733(a)(1). (c)

IRC

Section 9820 of the Internal Revenue Code of 1986 is amended—(1)in subsection (a)—(A)in paragraph (1)—(i)by striking For plan years beginning on or after January 1, 2022, each and inserting Each; (ii)in subparagraph (C), by striking ; and and inserting a semicolon;(iii)in subparagraph (D), by striking the period and inserting ; and; and(iv)by adding at the end the following:

(E)ensure that any directory, including the database described in subparagraph (C), containing provider directory information with respect to such plan complies with the requirements developed by the appropriate agencies in accordance with paragraph (6) in order to ensure that participants, beneficiaries, and enrollees are able to identify actively participating health care providers and health care facilities.

;

(C)information, in plain language, concerning the rights of the participant, beneficiary, or enrollee to cost-sharing protections pursuant to subsection (b) in the event of reliance on inaccurate provider network information supplied by a group health plan, and contact information for, as appropriate, the State consumer assistance program or ombudsman or the Employee Benefits Security Administration for more information.

;

(D)in paragraph (5), by adding at the end the following: Such information shall include a statement, in plain language, concerning the rights of the participant, beneficiary, or enrollee to cost-sharing protections pursuant to subsection (b) in the event of reliance on inaccurate provider directory information supplied by a group health plan, and contact information for, as appropriate, the State consumer assistance program or ombudsman or the Employee Benefits Security Administration for more information.;(E)by redesignating paragraphs (6) and (7) as paragraphs (8) and (9), respectively; (F)by inserting after paragraph (5) the following:

(6)

Protecting participants, beneficiaries, and enrollees from ghost networks

The Secretary, in collaboration with the Secretary of Labor and the Secretary of Health and Human Services, shall—(A)not later than 4 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, issue final regulations further defining the term ghost network (as defined in paragraph (8)); and(B)not later than 4 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, issue final regulations, subregulatory guidance, or program instruction on how to assess ghost networks in health plan directories including reasonable assumptions related to statistics and research methods.(7)

Database reporting and auditing to protect against ghost networks

(A)

Reporting requirements

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan shall submit to the Secretary, at such time as the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall require, but not less frequently than annually, the directory data described in paragraph (a)(4), in a machine readable format (as defined in section 147.210(a)(2)(xiv) of title 45, Code of Federal Regulations (or any successor regulations)). A third party administrator of a group health plan may submit such information for all group health plans, collectively, that such administrator administers. The Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall make data submitted under this subparagraph available on a public website.(B)

Provider directory independent audit requirements

(i)

In general

Beginning not later than 3 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, each group health plan shall conduct an annual directory audit, through an independent entity not associated with the health plan, that considers the factors described in clause (ii)(I)(aa) and follows the guidelines developed under clause (ii)(I)(bb).(ii)

Information to be included

(I)

In general

For purposes of carrying out the audits under this subparagraph, the Secretary shall—(aa)develop a list of information required to be included; and(bb)provide guidelines for carrying out such audits, for use by group health plans, on—(AA)the reasonable assumptions and research methods to select a reasonable sample in order to assess provider directory information accuracy; and (BB)determining the criteria of an eligible auditor. (II)

Contents

The information listed under subclause (I)(aa) shall include the following:(aa)The proportion of directory listings of the plan with inaccurate information, including incorrect contact information, as specified by the Secretary, during the audit period.(bb)The number of in-network items or services paid on behalf of participants, beneficiaries, and enrollees in the plan to providers or facilities who have a network provider contract with the health plan and were not listed in the directory of the health plan for the audit period. (cc)The resources of the plan to help participants, beneficiaries, and enrollees locate an accurately listed in-network provider who is accepting new patients.(dd)The proportion of participants, beneficiaries, and enrollees using out-of-network providers for mental health and substance use disorder services, and the proportion of participants, beneficiaries, and enrollees using out-of-network providers and facilities for medical and surgical services.(ee)Documentation that the plan verifies the accuracy of the provider directory information every 90 days.(ff)Other factors as determined by the Secretary.(iii)

Standards for reporting

An audit under this subparagraph is complete if all of the following conditions are met: (I) The audit report includes the following:(aa)A statement by the independent auditor that, to the best of the auditor's knowledge, the report is complete and accurate, and that reasonable assumptions related to statistics and research methods have been complied with.(bb)A statement explaining the assumptions, statistics, and methods used to select the sample and assess provider directory information accuracy.(cc)Such other requirements as the Secretary determines necessary.(II)The group health plan makes the independent audit available on a public website.(iv)

Rulemaking

The Secretary, the Secretary of Labor, and the Secretary of Health and Human Services shall issue interim final regulations (without prior notice and comment as generally required under section 553 of title 5, United States Code) concerning the national standards for conducting audits under this subparagraph, not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act.(C)

Audits by the Secretary

(i)

In general

Selection of plans

The Secretary, the Secretary of Labor, and the Secretary of Health and Human Services (referred to in this clause as the Secretaries), jointly, shall conduct annual audits of the submissions under subparagraph (B) of a total of not fewer than 10 group health plans, as determined by the Secretaries, that are the subjects of complaints about ghost networks or other complaints, or that are randomly selected by the Secretaries.

; and

(G)in paragraph (8), as so redesignated—(i)in the paragraph heading, by striking

Definition

and inserting

Definitions

;(ii)by striking For purposes of this subsection, the term and inserting the following: “For purposes of this subsection:

(A)

Provider directory information

The term

;

(iii)by striking group health plan, the name, address and inserting “group health plan—

(i)the name, address where the provider regularly sees patients

;

(iv)by striking the period and inserting ; and; and(v)by adding at the end the following:

Ghost network

The term ghost network means a group health plan for which the provider directory information describing the network of such plan—(i)includes inaccurate contact information with respect to a substantial share of included listings and providers who are part of the network; (ii)includes a substantial number of providers and facilities (as specified by the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services) in a specialty who are not accepting new patients within a time period specified by such secretaries;(iii)includes a substantial number of providers and facilities that are not part of the network; or(iv)omits a substantial number of providers and facilities that are part of the network.

; and

(2)

Reconciliation requirement

If a nonparticipating provider was listed as a participating provider in the posted provider directory database, the group health plan shall, not later than 30 days after receiving the request for payment, notify the participant, beneficiary, or enrollee, in plain language, that the participant, beneficiary, or enrollee may be eligible for a refund from the group health plan if such participant, beneficiary, or enrollee paid the out of network cost-sharing and did not receive a refund under section 2799B–9(b) of the Public Health Service Act (42 U.S.C. 300gg–139).

(d)

Effective date

The amendments made by subsections (a), (b), and (c) shall apply with respect to group health plans, or any health insurance issuer offering health insurance coverage in connection with such plan, for plan years beginning after the date that is 1 year after the date of enactment of this Act.

Provider requirements to protect patients and improve the accuracy of provider directory information

Section 2799B–9 of the Public Health Service Act (42 U.S.C. 300gg–139) is amended—(1)in subsection (a)—(A)in paragraph (3), by striking ; and and inserting a semicolon;(B)by redesignating paragraph (4) as paragraph (6); and(C)by inserting after paragraph (3) the following:

(4)subject to paragraph (5), when a provider or facility that is not accepting new patients determines that it has the ability to accept new patients, within 5 business days of such determination;(5)when a solo practitioner or small provider, as determined by the Secretary, determines that it has the ability to accept new patients, within 10 business days of such determination; and

; and

(2)by amending subsection (d) to read as follows:

(d)

Definition

For purposes of this section, the term provider directory information includes—(1)the name, address, specialty, telephone number, and digital contact information of each individual health care provider contracted to participate in any of the networks of the group health plan or health insurance coverage involved;(2)the name, address, specialty, telephone number, and digital contact information of each medical group, clinic, or facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved; and(3)with respect to each such provider, medical group, clinic, or facility—(A)whether such provider, medical group, clinic, or facility is accepting new patients;(B)the languages spoken and the availability of language translators for specified languages at each provider, medical group, clinic, or facility listed in the directory;(C)whether the provider, medical group, clinic, or facility offers medication-assisted treatment for opioid use disorder;(D)the State license number;(E)the national provider identifier;(F)the age groups served by such provider, group, clinic, or facility, such as pediatric, adolescent, adult, or geriatric populations;(G)whether such provider, group, clinic, or facility offers in-person services, telehealth services, or both; and(H)the cost-sharing tier, if applicable.

Strengthening mental health and substance use disorder parity requirements

(a)

PHSA

(1)

Network adequacy requirements

Section 2726(a) of the Public Health Service Act (42 U.S.C. 300gg–26(a)) is amended by adding at the end the following:

(9)

Network adequacy requirements

(A)

In general

The Secretary, the Secretary of Labor, and the Secretary of the Treasury shall issue regulations establishing national quantitative standards for mental health and substance use disorder network adequacy. Such standards shall consider—(i)the ratio of in-network mental health providers who submitted claims under the plan or coverage in the previous plan year, separated by professional type of mental health provider, to participants, beneficiaries, and enrollees in a group health plan or health insurance coverage; (ii)the ratio of in-network substance use disorder providers who submitted claims under the plan or coverage in the previous plan year, separated by professional type of substance use disorder provider, to participants, beneficiaries, and enrollees in a group health plan or health insurance coverage;(iii)separately, for mental health services and substance use disorder services—(I)geographic accessibility of providers;(II)geographic variation and population dispersion;(III)waiting times for appointments with participating providers; (IV)hours of operation for participating providers;(V)the ability of the network to meet the needs of participants, beneficiaries, and enrollees, including low-income individuals, individuals who are members of a racial or ethnic minority, individuals who live in a health professional shortage area, children and adults with serious, chronic, and complex health conditions, individuals with physical or mental disabilities or substance use disorders, pediatric populations, and individuals with limited English proficiency; (VI)the availability of in-person services, telehealth services, and hybrid services to serve the needs of participants, beneficiaries, and enrollees; and(VII)the percentage of in-network providers who have submitted a claim for payment during a previous 6-month period, as determined by the Secretary, the Secretary of Labor, and the Secretary of the Treasury; and(iv)other standards as determined by the Secretary, the Secretary of Labor, and the Secretary of the Treasury.(B)

Timing

(i)

Issuance

The Secretary, the Secretary of Labor, and the Secretary of the Treasury shall—(I)issue proposed regulations required under subparagraph (A) not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act; and(II)issue final regulations under subparagraph (A) not later than 1 year thereafter.(ii)

Effective date

The regulations promulgated under this paragraph shall take effect in the first plan year that begins after the date on which such final regulations are issued.(C)

Audits

The Secretary, the Secretary of Labor, and the Secretary of the Treasury (referred to in this subparagraph as the Secretaries), jointly, shall conduct annual, targeted audits of not fewer than 10 group health plans and health insurance issuers offering group or individual health insurance coverage that the Secretaries select based upon the number of complaints about mental health and substance use disorder network adequacy to ensure compliance with the requirements of this paragraph. Such audits shall begin not earlier than one year after the final regulations implementing this paragraph begin to apply to group health plans and health insurance issuers.

(2)

Definitions

Paragraphs (4) and (5) of section 2726(e) of the Public Health Service Act (42 U.S.C. 300gg–26(e)) are amended to read as follows:

(4)

Mental health benefits

The term mental health benefits means benefits with respect to services related to a mental health condition, defined consistently with generally recognized independent standards of current medical practice, such as the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.(5)

Substance use disorder benefits

The term substance use disorder benefits means benefits with respect to services related to a substance use disorder, defined consistently with generally recognized independent standards of current medical practice, such as the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

(3)

Standards for parity in reimbursement rates

Section 2726(a) of the Public Health Service Act (42 U.S.C. 300gg–26(a)), as amended by paragraph (1), is further amended by adding at the end the following:

(10)

Standards for parity in reimbursement rates

(A)

In general

Not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, the Secretary, the Secretary of Labor, and the Secretary of the Treasury shall issue regulations on a standard for parity in reimbursement rates for mental health or substance use disorder benefits and medical and surgical benefits, based on a comparative analysis conducted by such Secretaries using data submitted by group health plans and health insurance issuers, provider associations, and other experts related to the cost of care delivery for mental health and substance use disorder benefits.(B)

Requests for data

Group health plans and health insurance issuers shall comply with any request for data issued by the Secretary, the Secretary of Labor, and the Secretary of the Treasury for purposes of developing the standards under subparagraph (A), in a manner that avoids unnecessary duplication.(C)

Effective date

The regulations promulgated under subparagraph (A) shall apply to group health plans and health insurance issuers offering group or individual health insurance coverage beginning in the first plan year that begins after issuance of the final regulations.

(b)

ERISA

(1)

Network adequacy requirements

Section 712(a) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a(a)) is amended by adding at the end the following:

(9)

Network adequacy requirements

(A)

In general

The Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury shall issue regulations establishing national quantitative standards for mental health and substance use disorder network adequacy. Such standards shall consider—(i)the ratio of in-network mental health providers who submitted claims under the plan or coverage in the previous plan year, separated by professional type of mental health provider, to participants, beneficiaries, and enrollees in a group health plan or health insurance coverage; (ii)the ratio of in-network substance use disorder providers who submitted claims under the plan or coverage in the previous plan year, separated by professional type of substance use disorder provider, to participants, beneficiaries, and enrollees in a group health plan or health insurance coverage;(iii)separately, for mental health services and substance use disorder services—(I)geographic accessibility of providers;(II)geographic variation and population dispersion;(III)waiting times for appointments with participating providers; (IV)hours of operation for participating providers;(V)the ability of the network to meet the needs of participants, beneficiaries, and enrollees, including low-income individuals, individuals who are members of a racial or ethnic minority, individuals who live in a health professional shortage area, children and adults with serious, chronic, and complex health conditions, individuals with physical or mental disabilities or substance use disorders, pediatric populations, and individuals with limited English proficiency; (VI)the availability of in-person services, telehealth services, and hybrid services to serve the needs of participants, beneficiaries, and enrollees; and(VII)the percentage of in-network providers who have submitted a claim for payment during a previous 6-month period, as determined by the Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury; and(iv)other standards as determined by the Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury.(B)

Timing

(i)

Issuance

The Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury shall—(I)issue proposed regulations required under subparagraph (A) not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act; and(II)issue final regulations under subparagraph (A) not later than 1 year thereafter.(ii)

Effective date

The regulations promulgated under this paragraph shall take effect in the first plan year that begins after the date on which such final regulations are issued.(C)

Audits

The Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury (referred to in this subparagraph as the Secretaries), jointly, shall conduct annual, targeted audits of not fewer than 10 group health plans and health insurance issuers offering group health insurance coverage that the Secretaries select based upon the number of complaints about mental health and substance use disorder network adequacy to ensure compliance with the requirements of this paragraph. Such audits shall begin not earlier than one year after the final regulations implementing this paragraph begin to apply to group health plans and health insurance issuers.

(2)

Definitions

Paragraphs (4) and (5) of section 712(e) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a(e)) are amended to read as follows:

(4)

Mental health benefits

Substance use disorder benefits

(3)

Standards for parity in reimbursement rates

Section 712(a) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a(a)), as amended by paragraph (1), is further amended by adding at the end the following:

(10)

Standards for parity in reimbursement rates

(A)

In general

Not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, the Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury shall issue regulations on a standard for parity in reimbursement rates for mental health or substance use disorder benefits and medical and surgical benefits, based on a comparative analysis conducted by such Secretaries using data submitted by group health plans and health insurance issuers, provider associations, and other experts related to the cost of care delivery for mental health and substance use disorder benefits.(B)

Requests for data

Group health plans and health insurance issuers shall comply with any request for data issued by the Secretary, the Secretary of Health and Human Services, and the Secretary of the Treasury for purposes of developing the standards under subparagraph (A), in a manner that avoids unnecessary duplication.(C)

Effective date

The regulations promulgated under subparagraph (A) shall apply to group health plans and health insurance issuers offering group health insurance coverage beginning in the first plan year that begins after issuance of the final regulations.

(c)

IRC

(1)

Network adequacy requirements

Section 9812(a) of the Internal Revenue Code of 1986 is amended by adding at the end the following:

(9)

Network adequacy requirements

(A)

In general

The Secretary, the Secretary of Health and Human Services, and the Secretary of Labor shall issue regulations establishing national quantitative standards for mental health and substance use disorder network adequacy. Such standards shall consider—(i)the ratio of in-network mental health providers who submitted claims under the plan in the previous plan year, separated by professional type of mental health provider, to participants, beneficiaries, and enrollees in a group health plan; (ii)the ratio of in-network substance use disorder providers who submitted claims under the plan in the previous plan year, separated by professional type of substance use disorder provider, to participants, beneficiaries, and enrollees in a group health plan;(iii)separately, for mental health services and substance use disorder services—(I)geographic accessibility of providers;(II)geographic variation and population dispersion;(III)waiting times for appointments with participating providers; (IV)hours of operation for participating providers;(V)the ability of the network to meet the needs of participants, beneficiaries, and enrollees, including low-income individuals, individuals who are members of a racial or ethnic minority, individuals who live in a health professional shortage area, children and adults with serious, chronic, and complex health conditions, individuals with physical or mental disabilities or substance use disorders, pediatric populations, and individuals with limited English proficiency; (VI)the availability of in-person services, telehealth services, and hybrid services to serve the needs of participants, beneficiaries, and enrollees; and(VII)the percentage of in-network providers who have submitted a claim for payment during a previous 6-month period, as determined by the Secretary, the Secretary of Health and Human Services, and the Secretary of Labor; and(iv)other standards as determined by the Secretary, the Secretary of Health and Human Services, and the Secretary of Labor.(B)

Timing

(i)

Issuance

The Secretary, the Secretary of Health and Human Services, and the Secretary of Labor shall—(I)issue proposed regulations required under subparagraph (A) not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act; and(II)issue final regulations under subparagraph (A) not later than 1 year thereafter.(ii)

Effective date

The regulations promulgated under this paragraph shall take effect in the first plan year that begins after the date on which such final regulations are issued.(C)

Audits

The Secretary, the Secretary of Health and Human Services, and the Secretary of Labor (referred to in this subparagraph as the Secretaries), jointly, shall conduct annual, targeted audits of not fewer than 10 group health plans that the Secretaries select based upon the number of complaints about mental health and substance use disorder network adequacy to ensure compliance with the requirements of this paragraph. Such audits shall begin not earlier than one year after the final regulations implementing this paragraph begin to apply to group health plans.

(2)

Definitions

Paragraphs (4) and (5) of section 9812(e) of the Internal Revenue Code of 1986 are amended to read as follows:

(4)

Mental health benefits

Substance use disorder benefits

(3)

Standards for parity in reimbursement rates

Section 9812(a) of the Internal Revenue Code of 1986, as amended by paragraph (1), is further amended by adding at the end the following:

(10)

Standards for parity in reimbursement rates

(A)

In general

Not later than 2 years after the date of enactment of the Behavioral Health Network and Directory Improvement Act, the Secretary, the Secretary of Health and Human Services, and the Secretary of Labor shall issue regulations on a standard for parity in reimbursement rates for mental health or substance use disorder benefits and medical and surgical benefits, based on a comparative analysis conducted by such Secretaries using data submitted by group health plans, provider associations, and other experts related to the cost of care delivery for mental health and substance use disorder benefits.(B)

Requests for data

Group health plans shall comply with any request for data issued by the Secretary, the Secretary of Health and Human Services, and the Secretary of Labor for purposes of developing the standards under subparagraph (A), in a manner that avoids unnecessary duplication.(C)

Effective date

The regulations promulgated under subparagraph (A) shall apply to group health plans beginning in the first plan year that begins after issuance of the final regulations.

State and Tribal ombudsman programs relating to mental health and substance use disorder parity

Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–91 et seq.) is amended—(1)by redesignating section 2794 (42 U.S.C. 300gg–95) (regarding uniform fraud and abuse referral format), as added by section 6603 of the Patient Protection and Affordable Care Act (Public Law 111–148), as section 2795; and(2)by adding at the end the following:

2796.

State and Tribal ombudsman programs relating to mental health and substance use disorder parity

(a)

In general

The Secretary shall make grants to eligible entities, designated by a State, Indian Tribe, or Tribal organization, as described in subsection (b), for the purpose of—(1)establishing or supporting State and Tribal mental health and substance use disorder parity ombudsman programs to—(A)educate consumers about the mental health and substance use disorder coverage in individual plans, group health plans, self-insured plans, and State Medicaid managed care plans;(B)assist consumers in understanding their rights as health benefits plan members, including appeal processes and how to use such benefits, and how to access appropriate medical information;(C)assist consumers in exercising their rights under the provisions of part D, including resolving problems related to a group health plan or health insurance issuer erroneously charging a consumer out-of-network rates for services listed in-network on the group health plan or health insurance issuer’s provider directory;(D)identify, investigate, and help resolve complaints related to mental health and substance use disorder coverage (including potential violations of the mental health and substance use disorder parity laws) on behalf of consumers;(E)maintain a toll-free hotline and website for consumers; (F)collect, track, and quantify problems and inquiries encountered by consumers; and(G)other activities as defined by the Secretary; and(2)provide support and training for such State and Tribal mental health parity ombudsman programs (such as through the establishment of a mental health parity ombudsman program resource center).(b)

Eligibility

To be eligible to receive a grant under this section, a State, Indian Tribe, or Tribal organization shall designate an ombudsman or consumer assistance program or other independent entity that—(1)has specialized knowledge of mental health conditions and substance use disorders and experience resolving inquiries and complaints; and(2)directly, or in coordination with departments of insurance, and consumer assistance organizations, receives and responds to inquiries and complaints concerning access to mental health and substance use disorder services.(c)

Criteria

A State, Indian Tribe, or Tribal organization that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.(d)

Data collection

As a condition of receiving a grant, an eligible entity shall agree to—(1)collect and report data to the Secretary, State legislature, and relevant State agencies, including the departments of insurance and the State attorney general, on the numbers and types of problems and inquiries encountered by individuals with respect to access to behavioral health services; and (2)report to the Secretary on how identified problems were addressed, including through promising practices related to responding to mental health and substance use disorder coverage issues, including appeals and education.(e)

Report to congress

Not later than 4 years after the date of the enactment of the Behavioral Health Network and Directory Improvement Act, the Secretary shall submit to Congress a report on the data collected under subsection.(f)

Definitions

In this section, the terms Indian Tribe and Tribal organization have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act.(g)

Authorization of appropriations

To carry out this section, there are authorized to be appropriated $20,000,000 for fiscal year 2025 and $10,000,000 for fiscal year 2026 and each fiscal year thereafter.

Report to Congress

(a)

In general

Not later than 6 years after the date of enactment of this Act and every 2 years for the next 10 years, the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury (collectively referred to in this section as the Secretaries) shall jointly submit to Congress and make publicly available a report to assess the prevalence of ghost networks and the adequacy of mental health and substance use disorder networks, in accordance with section 2726(a)(9) of the Public Health Service Act, section 712(a)(9) of the Employee Retirement Income Security Act of 1974, and section 9812(a)(9) of the Internal Revenue Code of 1986, as amended by section 4. Such report shall include the following:(1)Aggregate information about group health plans and health insurance issuers determined by the Secretaries to be out of compliance with the provider directory requirements under section 2799A–5 of the Public Health Service Act, section 720 of the Employee Retirement Income Security Act of 1974, and section 9820 of the Internal Revenue Code of 1986, as amended by section 2.(2)Aggregate information about group health plans and health insurance issuers determined by the Secretaries to be out of compliance with the requirements for parity in mental health and substance use disorder benefits under section 2726 of the Public Health Service Act (42 U.S.C. 300gg–26), section 712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a), and section 9812 of the Internal Revenue Code of 1986, as amended by section 4.(3)A summary of findings through audits, in the aggregate, under section 2799A–5(a)(7)(C) of the Public Health Service Act, section 720(a)(7)(C) of the Employee Retirement Income Security Act of 1974, and section 9820(a)(7)(C) of the Internal Revenue Code of 1986, as amended by section 2, including—(A)the accuracy of provider directory information, sectioned out by accuracy of the provider’s name, address, specialty, telephone number, digital contact information, whether the providers are accepting new patients, in-network status, linguistic- and cultural-competency, and availability of medications for opioid use disorder;(B)the number of plans and individuals enrolled in a group health plan or group or individual health insurance coverage that offers a mental health and substance use disorder network that meets the network adequacy standards under, as applicable, section 2799A–5 of the Public Health Service Act, section 720 of the Employee Retirement Income Security Act of 1974, or section 9820 of the Internal Revenue Code of 1986, as amended by section 2; and(C)the number of individuals enrolled in a group health plan or group or individual health insurance coverage with a ghost network.(4)A comparative analysis of in-network and out-of-network reimbursement rates for mental health and substance use disorder services compared to medical and surgical services by group health plans and health insurance issuers.(b)

Definition

In this section, the term ghost network has the meaning given such term in section 2799A–5(a)(8) of the Public Health Service Act, section 720(a)(8) of the Employee Retirement Income Security Act of 1974, and section 9820(a)(8) of the Internal Revenue Code of 1986, as amended by section 2.

Authorization of appropriations

(a)

Administrative functions

To carry out sections 4, 5, and 6, including the amendments made by such sections, there are authorized to be appropriated to the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury such sums as may be necessary.(b)

Protecting patients and improving the accuracy of provider directory information

To carry out section 2, including the amendments made by such section, in addition to amounts otherwise made available for such purposes, there are authorized to be appropriated—(1)to the Secretary of Health and Human Services, for purposes of carrying out the amendments made by subsection (a) of such section—(A)$15,200,000 for each of fiscal years 2025 and 2026;(B)$17,000,000 for fiscal year 2027; and(C)$10,000,000 for fiscal year 2028 and each fiscal year thereafter; and(2)to the Secretary of Labor, for purposes of carrying out the amendments made by subsection (b) of such section, $22,000,000 for fiscal year 2025 and each fiscal year thereafter.