Short title

This Act may be cited as the

Fairness in Autism Treatment Act of 2007

Amendments to the Employee Retirement Income Security Act of 1974

(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 for pervasive developmental disorders

(a)

In general

A group health plan (and a health insurance issuer providing health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits shall provide coverage for pervasive developmental disorders, including coverage for therapeutic, respite, and rehabilitative care for participants or beneficiaries who have not attained 22 years of age. (b)

In-network and out-of-network standards

(1)

In general

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides benefits for pervasive developmental disorders, and that provides both in-network benefits for such disorders and out-of-network benefits for such disorders, the requirements of this section shall apply separately with respect to benefits provided under the plan (or coverage) on an in-network basis and benefits provided under the plan (or coverage) on an out-of-network basis. (2)

Clarification

Nothing in paragraph (1) shall be construed as requiring that a group health plan (or health insurance coverage offered in connection with such a plan) eliminate an out-of-network provider option from such plan (or coverage) pursuant to the terms of the plan (or coverage). (c)

Other requirements

(1)

Annual or lifetime dollar limitations

A group health plan (or health insurance coverage offered in connection with such a plan) may not impose any annual or lifetime dollar limitation on benefits for pervasive developmental disorders unless such limitation applies to all medical and surgical benefits and benefits for pervasive developmental disorders under the plan (or coverage). (2)

Cost sharing

A group health plan (or health insurance coverage offered in connection with such a plan) may not impose a deductible, coinsurance, or other cost-sharing with respect to the coverage of pervasive developmental disorders under the plan (or coverage), which is greater than the deductible, coinsurance, or other cost-sharing, as the case may be, imposed with respect to medical and surgical benefits under the plan (or coverage). (3)

Eligibility to enroll or renew

A group health plan (or a health insurance issuer providing health insurance coverage offered in connection with such a plan) may not deny eligibility, or continued eligibility, to enroll or to renew coverage under the term of the plan (or coverage), solely for the purpose of avoiding the requirements of this section. (d)

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 the last sentence of section 102(a), for purposes of assuring notice of such requirements under the plan; except that the summary description required to be provided under the fourth sentence of 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. (e)

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 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar 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 group health insurance coverage offered in connection with a group health plan) if the application of this section to such plan (or coverage) results in an increase in the cost under the plan (or coverage) of at least 1 percent. (f)

Pervasive developmental disorder defined

For purposes of this section, the term pervasive developmental disorder means any developmental disability (as defined in section 102(8) of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002(8))). (g)

Preemption, relation to State laws

(1)

In general

Nothing in this section shall be construed to preempt any State law in effect with respect to health insurance coverage to the extent the requirements of such law at least meet the requirements of this section. (2)

ERISA

Nothing in this section shall be construed to affect or modify the provisions of section 514 with respect to group health plans.

(b)

Conforming amendments

(1)Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking section 711 and inserting sections 711 and 714. (2)Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking section 711 and inserting sections 711 and 714. (c)

Clerical amendment

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:

Sec. 714. Parity for pervasive developmental disorders.

(d)

Effective date

The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2009.

Amendments to Internal Revenue Code of 1986

(a)

In general

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

9813.

Parity for pervasive developmental disorders

(a)

In general

A group health plan that provides both medical and surgical benefits shall provide coverage for pervasive developmental disorders, including coverage for therapeutic, respite, and rehabilitative care for participants or beneficiaries who have not attained 22 years of age. (b)

In-network and out-of-network standards

(1)

In general

In the case of a group health plan that provides benefits for pervasive developmental disorders, and that provides both in-network benefits for such disorders and out-of-network benefits for such disorders, the requirements of this section shall apply separately with respect to benefits provided under the plan on an in-network basis and benefits provided under the plan on an out-of-network basis. (2)

Clarification

Nothing in paragraph (1) shall be construed as requiring that a group health plan eliminate an out-of-network provider option from such plan pursuant to the terms of the plan. (c)

Other requirements

(1)

Annual or lifetime dollar limitations

A group health plan may not impose any annual or lifetime dollar limitation on benefits for pervasive developmental disorders unless such limitation applies to all medical and surgical benefits and benefits for pervasive developmental disorders provided under the plan. (2)

Cost sharing

A group health plan may not impose a deductible, coinsurance, or other cost-sharing with respect to the coverage of pervasive developmental disorders under the plan, which is greater than the deductible, coinsurance, or other cost-sharing, as the case may be, imposed with respect to medical and surgical benefits under the plan. (3)

Eligibility to enroll or renew

A group health plan may not deny eligibility, or continued eligibility, to enroll or to renew coverage under the term of the plan, solely for the purpose of avoiding the requirements of this section. (d)

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, with respect to a calendar year and a plan year, an employer who employed an average of at least 2 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year. For purposes of the preceding sentence, all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 shall be treated as 1 employer and rules similar to rules of subparagraphs (B) and (C) of section 4980D(d)(2) shall apply. (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. (e)

Pervasive developmental disorder defined

(b)

Conforming amendments

The table of sections for subchapter B of chapter 100 of such Code is amended by adding at the end the following new item:

Sec. 9813. Parity for pervasive developmental disorders.

(c)

Effective date

The amendments made by this section shall apply with respect to group health plans for plan years beginning on or after January 1, 2009.