II 109th CONGRESS 1st Session S. 803 IN THE SENATE OF THE UNITED STATES April 14, 2005 Mr. Coleman (for himself and Mrs. Clinton) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Employee Retirement Income Security Act of 1974, the Public Health Service Act, and the Internal Revenue Code of 1986 to provide parity with respect to substance abuse treatment benefits under group health plans and health insurance coverage.

1.

Short title

This Act may be cited as the Help Expand Access to Recovery and Treatment Act of 2005 or the HEART Act.

2.

Findings

Congress finds the following: (1)Substance abuse, if left untreated, is a medical emergency and a private and public health crisis. (2)Nothing in this Act should be construed as prohibiting application of the concept of parity to substance abuse treatment provided by faith-based treatment providers.

3.

Parity in substance abuse treatment benefits

(a)

Group health plans

(1)

Public health service act amendments

(A)

In general

Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–4 et seq.) is amended by adding at the end the following new section:

2707.

Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits

(a)

In general

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and substance abuse treatment benefits, the plan or coverage shall not impose treatment limitations or financial requirements on the substance abuse treatment benefits unless similar limitations or requirements are imposed for medical and surgical benefits. (b)

Construction

Nothing in this section shall be construed— (1)as requiring a group health plan (or health insurance coverage offered in connection with such a plan) to provide any substance abuse treatment benefits; or (2)to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section. (c)

Exemptions

(1)

Small employer exemption

(A)

In general

This section shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year of a small employer. (B)

Small employer

For purposes of subparagraph (A), the term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. (C)

Application of certain rules in determination of employer size

For purposes of this paragraph— (i)

Application of aggregation rule for employers

Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 of the Internal Revenue Code of 1986 shall apply for purposes of treating persons as a single employer. (ii)

Employers not in existence in preceding year

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year. (iii)

Predecessors

Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer. (2)

Increased cost exemption

This section shall not apply with respect to a group health plan (or health insurance coverage offered in connection with a group health plan) if the application of this section to such plan (or to such coverage) results in an increase in the cost under the plan (or for such coverage) of at least 1 percent. (d)

Separate application to each option offered

In the case of a group health plan that offers a participant or beneficiary 2 or more benefit package options under the plan, the requirements of this section shall be applied separately with respect to each such option. (e)

Definitions

For purposes of this section: (1)

Treatment limitation

The term treatment limitation means, with respect to benefits under a group health plan or health insurance coverage, any day or visit limits imposed on coverage of benefits under the plan or coverage during a period of time. (2)

Financial requirement

The term financial requirement means, with respect to benefits under a group health plan or health insurance coverage, any deductible, coinsurance, or cost-sharing or an annual or lifetime dollar limit imposed with respect to the benefits under the plan or coverage. (3)

Medical or surgical benefits

The term medical or surgical benefits means benefits with respect to medical or surgical services, as defined under the terms of the plan or coverage (as the case may be), but does not include substance abuse treatment benefits. (4)

Substance abuse treatment benefits

The term substance abuse treatment benefits means benefits with respect to substance abuse treatment services. (5)

Substance abuse treatment services

The term substance abuse treatment services means any of the following items and services provided for the treatment of substance abuse: (A)Inpatient treatment, including detoxification. (B)Nonhospital residential treatment. (C)Outpatient treatment, including screening and assessment, medication management, individual, group, and family counseling, and relapse prevention. (D)Prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for substance abuse. (6)

Substance abuse

The term substance abuse includes chemical dependency. (f)

Notice

A group health plan under this part shall comply with the notice requirement under section 714(f) of the Employee Retirement Income Security Act of 1974 with respect to the requirements of this section as if such section applied to such plan.

. (B)

Conforming amendment

Section 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is amended by striking section 2704 and inserting sections 2704 and 2707. (2)

ERISA amendments

(A)

In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:

714.

Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits

(a)

In general

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and substance abuse treatment benefits, the plan or coverage shall not impose treatment limitations or financial requirements on the substance abuse treatment benefits unless similar limitations or requirements are imposed for medical and surgical benefits. (b)

Construction

Nothing in this section shall be construed— (1)as requiring a group health plan (or health insurance coverage offered in connection with such a plan) to provide any substance abuse treatment benefits; or (2)to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section. (c)

Exemptions

(1)

Small employer exemption

(A)

In general

This section shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year of a small employer. (B)

Small employer

For purposes of subparagraph (A), the term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. (C)

Application of certain rules in determination of employer size

For purposes of this paragraph— (i)

Application of aggregation rule for employers

Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 of the Internal Revenue Code of 1986 shall apply for purposes of treating persons as a single employer. (ii)

Employers not in existence in preceding year

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year. (iii)

Predecessors

Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer. (2)

Increased cost exemption

This section shall not apply with respect to a group health plan (or health insurance coverage offered in connection with a group health plan) if the application of this section to such plan (or to such coverage) results in an increase in the cost under the plan (or for such coverage) of at least 1 percent. (d)

Separate application to each option offered

In the case of a group health plan that offers a participant or beneficiary 2 or more benefit package options under the plan, the requirements of this section shall be applied separately with respect to each such option. (e)

Definitions

For purposes of this section: (1)

Treatment limitation

The term treatment limitation means, with respect to benefits under a group health plan or health insurance coverage, any day or visit limits imposed on coverage of benefits under the plan or coverage during a period of time. (2)

Financial requirement

The term financial requirement means, with respect to benefits under a group health plan or health insurance coverage, any deductible, coinsurance, or cost-sharing or an annual or lifetime dollar limit imposed with respect to the benefits under the plan or coverage. (3)

Medical or surgical benefits

The term medical or surgical benefits means benefits with respect to medical or surgical services, as defined under the terms of the plan or coverage (as the case may be), but does not include substance abuse treatment benefits. (4)

Substance abuse treatment benefits

The term substance abuse treatment benefits means benefits with respect to substance abuse treatment services. (5)

Substance abuse treatment services

The term substance abuse treatment services means any of the following items and services provided for the treatment of substance abuse: (A)Inpatient treatment, including detoxification. (B)Nonhospital residential treatment. (C)Outpatient treatment, including screening and assessment, medication management, individual, group, and family counseling, and relapse prevention. (D)Prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for substance abuse. (6)

Substance abuse

The term substance abuse includes chemical dependency. (f)

Notice under group health plan

The imposition of the requirements of this section shall be treated as a material modification in the terms of the plan described in section 102(a), for purposes of assuring notice of such requirements under the plan; except that the summary description required to be provided under section 104(b)(1) with respect to such modification shall be provided by not later than 60 days after the first day of the first plan year in which such requirements apply.

. (B)

Conforming amendments

(i)Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking section 711 and inserting sections 711 and 714. (ii)Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking section 711 and inserting sections 711 and 714. (iii)The table of contents in section 1 of such Act is amended by inserting after the item relating to section 713 the following new item: 714. Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits . (3)

Internal revenue code amendments

(A)

In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 (relating to other requirements) is amended by adding at the end the following new section:

9813.

Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits

(a)

In general

In the case of a group health plan that provides both medical and surgical benefits and substance abuse treatment benefits, the plan shall not impose treatment limitations or financial requirements on the substance abuse treatment benefits unless similar limitations or requirements are imposed for medical and surgical benefits. (b)

Construction

Nothing in this section shall be construed— (1)as requiring a group health plan to provide any substance abuse treatment benefits; or (2)to prevent a group health plan from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section. (c)

Exemptions

(1)

Small employer exemption

(A)

In general

This section shall not apply to any group health plan for any plan year of a small employer. (B)

Small employer

For purposes of subparagraph (A), the term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. (C)

Application of certain rules in determination of employer size

For purposes of this paragraph— (i)

Application of aggregation rule for employers

Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 shall apply for purposes of treating persons as a single employer. (ii)

Employers not in existence in preceding year

In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year. (iii)

Predecessors

Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer. (2)

Increased cost exemption

This section shall not apply with respect to a group health plan if the application of this section to such plan results in an increase in the cost under the plan of at least 1 percent. (d)

Separate application to each option offered

In the case of a group health plan that offers a participant or beneficiary 2 or more benefit package options under the plan, the requirements of this section shall be applied separately with respect to each such option. (e)

Definitions

For purposes of this section: (1)

Treatment limitation

The term treatment limitation means, with respect to benefits under a group health plan, any day or visit limits imposed on coverage of benefits under the plan during a period of time. (2)

Financial requirement

The term financial requirement means, with respect to benefits under a group health plan, any deductible, coinsurance, or cost-sharing or an annual or lifetime dollar limit imposed with respect to the benefits under the plan. (3)

Medical or surgical benefits

The term medical or surgical benefits means benefits with respect to medical or surgical services, as defined under the terms of the plan, but does not include substance abuse treatment benefits. (4)

Substance abuse treatment benefits

The term substance abuse treatment benefits means benefits with respect to substance abuse treatment services. (5)

Substance abuse treatment services

The term substance abuse treatment services means any of the following items and services provided for the treatment of substance abuse: (A)Inpatient treatment, including detoxification. (B)Nonhospital residential treatment. (C)Outpatient treatment, including screening and assessment, medication management, individual, group, and family counseling, and relapse prevention. (D)Prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for substance abuse. (6)

Substance abuse

The term substance abuse includes chemical dependency.

. (B)

Conforming amendments

(i)Section 4980D(d)(1) of such Code is amended by striking section 9811 and inserting sections 9811 and 9813. (ii)The table of sections of subchapter B of chapter 100 of such Code is amended by adding at the end the following new item: 9813. Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits . (b)

Individual health insurance

(1)

Amendment to the public health service act

Part B of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–41 et seq.) is amended by inserting after section 2752 the following new section:

2753.

Parity in the application of treatment limitations and financial requirements to substance abuse benefits

(a)

In general

The provisions of section 2707 (other than subsection (e)) shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as it applies to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market. (b)

Notice

A health insurance issuer under this part shall comply with the notice requirement under section 714(f) of the Employee Retirement Income Security Act of 1974 with respect to the requirements referred to in subsection (a) as if such section applied to such issuer and such issuer were a group health plan.

. (2)

Conforming amendment

Section 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by striking section 2751 and inserting sections 2751 and 2753. (c)

Effective dates

(1)

Group health plans

Subject to paragraph (3), the amendments made by subsection (a) apply with respect to group health plans for plan years beginning on or after January 1, 2006. (2)

Individual health insurance

The amendments made by subsection (b) apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2006. (3)

Special rule

In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of enactment of this Act, the amendments made by subsection (a) shall not apply to plan years beginning before the later of— (A)the date on which the last collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of enactment of this Act), or (B)January 1, 2006. For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by subsection (a) shall not be treated as a termination of such collective bargaining agreement.(d)

Coordinated regulations

Section 104(1) of the Health Insurance Portability and Accountability Act of 1996 is amended by striking this subtitle (and the amendments made by this subtitle and section 401) and inserting the provisions of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, and the provisions of parts A and C of title XXVII of the Public Health Service Act, and chapter 100 of the Internal Revenue Code of 1986. (e)

Preemption

Nothing in the amendments made by this section shall be construed to preempt any provision of State law that provides protections to individuals that are greater than the protections provided under such amendments.