[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4276 Introduced in House (IH)]

<DOC>






114th CONGRESS
  1st Session
                                H. R. 4276

   To strengthen parity in mental health and substance use disorder 
                               benefits.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           December 16, 2015

  Mr. Kennedy (for himself, Mr. Tonko, Ms. Matsui, Ms. Clarke of New 
 York, and Ms. Castor of Florida) introduced the following bill; which 
 was referred to the Committee on Energy and Commerce, and in addition 
 to the Committees on Education and the Workforce and Ways and Means, 
for a period to be subsequently determined by the Speaker, in each case 
for consideration of such provisions as fall within the jurisdiction of 
                        the committee concerned

_______________________________________________________________________

                                 A BILL


 
   To strengthen parity in mental health and substance use disorder 
                               benefits.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Behavioral Health Coverage 
Transparency Act of 2015''.

SEC. 2. STRENGTHENING PARITY IN MENTAL HEALTH AND SUBSTANCE USE 
              DISORDER BENEFITS.

    (a) Public Health Service Act.--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 new paragraphs:
            ``(6) Disclosure and enforcement requirements.--
                    ``(A) Disclosure requirements.--
                            ``(i) Regulations.--Not later than June 30, 
                        2016, the Secretary, in cooperation with the 
                        Secretaries of Labor and the Treasury, as 
                        appropriate, shall issue additional regulations 
                        for carrying out this section, including an 
                        explanation of documents that must be disclosed 
                        by plans and issuers, the process governing 
                        such disclosures by plans and issuers, and 
                        analyses that must be conducted by plans and 
                        issuers by a group health plan or health 
                        insurance issuer offering health insurance 
                        coverage in the group or individual market in 
                        order for such plan or issuer to demonstrate 
                        compliance with the provisions of this section.
                            ``(ii) Disclosure requirements.--Documents 
                        required to be disclosed by a group health plan 
                        or health insurance issuer offering health 
                        insurance coverage in the group or individual 
                        market under clause (i) shall include an annual 
                        report that details the specific analyses 
                        performed to ensure compliance of such plan or 
                        coverage with the law and regulations. At a 
                        minimum, with respect to the application of 
                        non-quantitative treatment limitations (in this 
                        paragraph referred to as NQTLs) to benefits 
                        under the plan or coverage, such report shall--
                                    ``(I) identify the specific factors 
                                the plan or coverage used in performing 
                                its NQTL analysis;
                                    ``(II) identify and define the 
                                specific evidentiary standards relied 
                                on to evaluate the factors;
                                    ``(III) describe how the 
                                evidentiary standards are applied to 
                                each service category for mental 
                                health, substance use disorders, 
                                medical benefits, and surgical 
                                benefits;
                                    ``(IV) disclose the results of the 
                                analyses of the specific evidentiary 
                                standards in each service category; and
                                    ``(V) disclose the specific 
                                findings of the plan or coverage in 
                                each service category and the 
                                conclusions reached with respect to 
                                whether the processes, strategies, 
                                evidentiary standards, or other factors 
                                used in applying the NQTL to mental 
                                health or substance use disorder 
                                benefits are comparable to, and applied 
                                no more stringently than, the 
                                processes, strategies, evidentiary 
                                standards, or other factors used in 
                                applying the limitation with respect to 
                                medical and surgical benefits in the 
                                same classification.
                            ``(iii) Guidance.--The Secretary, in 
                        cooperation with the Secretaries of Labor and 
                        the Treasury, as appropriate, shall issue 
                        guidance to group health plans and health 
                        insurance issuers offering health insurance 
                        coverage in the group or individual markets on 
                        how to satisfy the requirements of this section 
                        with respect to making information available to 
                        current and potential participants and 
                        beneficiaries. Such information shall include 
                        certificate of coverage documents and 
                        instruments under which the plan or coverage 
                        involved is administered and operated that 
                        specify, include, or refer to procedures, 
                        formulas, and methodologies applied to 
                        determine a participant or beneficiary's 
                        benefit under the plan or coverage, regardless 
                        of whether such information is contained in a 
                        document designated as the `plan document'. 
                        Such guidance shall include a disclosure of how 
                        the plan or coverage involved has provided that 
                        processes, strategies, evidentiary standards, 
                        and other factors used in applying the NQTL to 
                        mental health or substance use disorder 
                        benefits are comparable to, and applied no more 
                        stringently than, the processes, strategies, 
                        evidentiary standards, or other factors used in 
                        applying the limitation with respect to medical 
                        and surgical benefits in the same 
                        classification.
                            ``(iv) Definitions.--In this paragraph and 
                        paragraph (7), the terms `non-quantitative 
                        treatment limitations', `comparable to', and 
                        `applied no more stringently than' have the 
                        meanings given such terms in sections 146 and 
                        147 of title 45, Code of Federal Regulations 
                        (or any successor regulation).
                    ``(B) Enforcement.--
                            ``(i) Process for complaints.--The 
                        Secretary, in cooperation with the Secretaries 
                        of Labor and the Treasury, as appropriate, 
                        shall, with respect to group health plans and 
                        health insurance issuers offering health 
                        insurance coverage in the group or individual 
                        market, issue guidance to clarify the process 
                        and timeline for current and potential 
                        participants and beneficiaries (and authorized 
                        representatives and health care providers of 
                        such participants and beneficiaries) with 
                        respect to such plans and coverage to file 
                        formal complaints of such plans or issuers 
                        being in violation of this section, including 
                        guidance, by plan type, on the relevant State, 
                        regional, and national offices with which such 
                        complaints should be filed.
                            ``(ii) Authority for public enforcement.--
                        The Secretary, in consultation with the 
                        Secretaries of Labor and the Treasury, shall 
                        make available to the public on the Consumer 
                        Parity Portal website established under 
                        paragraph (7) de-identified information on 
                        audits and investigations of group health plans 
                        and health insurance issuers conducted under 
                        this section.
                            ``(iii) Audits.--
                                    ``(I) Randomized audits.--The 
                                Secretary in cooperation with the 
                                Secretaries of Labor and the Treasury, 
                                is authorized to conduct randomized 
                                audits of group health plans and health 
                                insurance issuers offering health 
                                insurance coverage in the group or 
                                individual market to determine 
                                compliance with this section. Such 
                                audits shall be conducted on no fewer 
                                than twelve plans and issuers per plan 
                                year. Information from such audits 
                                shall be made plainly available on the 
                                Consumer Parity Portal website 
                                established under paragraph (7).
                                    ``(II) Additional audits.--In the 
                                case of a group health plan or health 
                                insurance issuer offering health 
                                insurance coverage in the group or 
                                individual market with respect to which 
                                any claim has been filed during a plan 
                                year, the Secretary may audit the books 
                                and records of such plan or issuer to 
                                determine compliance with this section. 
                                Information detailing the results of 
                                the audit shall be made available on 
                                the Consumer Parity Portal website 
                                established under paragraph (7).
                            ``(iv) Denial rates.--The Secretary shall 
                        collect information on the rates of and reasons 
                        for denial by group health plans and health 
                        insurance issuers offering health insurance 
                        coverage in the group or individual market of 
                        claims for outpatient and inpatient mental 
                        health and substance use disorder services 
                        compared to the rates of and reasons for denial 
                        of claims for medical and surgical services. 
                        For the first plan year beginning at least two 
                        years after the date of the enactment of this 
                        paragraph and each subsequent plan year, the 
                        Secretary shall submit to the Energy and 
                        Commerce Committee of the House of 
                        Representatives and the Committee on Health, 
                        Education, Labor, and Pensions of the Senate, 
                        and make plainly available on the Consumer 
                        Parity Portal website under paragraph (7), the 
                        information collected under the previous 
                        sentence with respect to the previous plan 
                        year.
            ``(7) Consumer parity portal website.--The Secretary, in 
        consultation with the Secretaries of Labor and the Treasury, 
        shall establish a one-stop Internet website portal for--
                    ``(A) submitting complaints and violations relating 
                to this section, section 712 of the Employee Retirement 
                Income Security Act of 1974, and section 9812 of the 
                Internal Revenue Code of 1986; and
                    ``(B) for each of such Secretaries to submit 
                information in order to provide such information to 
                health care consumers pursuant to paragraph (6), 
                section 712(a)(6) of the Employee Retirement Income 
                Security Act of 1974, and section 9812(a)(6) of the 
                Internal Revenue Code of 1986.
        Such portal shall have the ability to take basic information 
        related to the complaint, including name, contact information, 
        and brief narrative, and transmit such information in a timely 
        fashion to the appropriate State or Federal enforcement agency. 
        Once the consumer information is submitted, such portal shall 
        provide the consumer with contact information for the 
        appropriate enforcement agency to follow-up on the 
        complaint.''.
    (b) Employee Retirement Income Security Act of 1974.--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 new 
paragraph:
            ``(6) Disclosure and enforcement requirements.--
                    ``(A) Disclosure requirements.--
                            ``(i) Regulations.--Not later than June 30, 
                        2016, the Secretary, in cooperation with the 
                        Secretaries of Health and Human Services and 
                        the Treasury, as appropriate, shall issue 
                        additional regulations for carrying out this 
                        section, including an explanation of documents 
                        that must be disclosed by plans and issuers, 
                        the process governing such disclosures by plans 
                        and issuers, and analyses that must be 
                        conducted by plans and issuers by a group 
                        health plan (and health insurance coverage 
                        offered in connection with such a plan) in 
                        order for such plan or issuer to demonstrate 
                        compliance with the provisions of this section.
                            ``(ii) Disclosure requirements.--Documents 
                        required to be disclosed by a group health plan 
                        (and health insurance coverage offered in 
                        connection with such a plan) under clause (i) 
                        shall include an annual report that details the 
                        specific analyses performed to ensure 
                        compliance of such plan or coverage with the 
                        law and regulations. At a minimum, with respect 
                        to the application of non-quantitative 
                        treatment limitations (in this paragraph 
                        referred to as NQTLs) to benefits under the 
                        plan or coverage, such report shall--
                                    ``(I) identify the specific factors 
                                the plan or coverage used in performing 
                                its NQTL analysis;
                                    ``(II) identify and define the 
                                specific evidentiary standards relied 
                                on to evaluate the factors;
                                    ``(III) describe how the 
                                evidentiary standards are applied to 
                                each service category for mental 
                                health, substance use disorders, 
                                medical benefits, and surgical 
                                benefits;
                                    ``(IV) disclose the results of the 
                                analyses of the specific evidentiary 
                                standards in each service category; and
                                    ``(V) disclose the specific 
                                findings of the plan or coverage in 
                                each service category and the 
                                conclusions reached with respect to 
                                whether the processes, strategies, 
                                evidentiary standards, or other factors 
                                used in applying the NQTL to mental 
                                health or substance use disorder 
                                benefits are comparable to, and applied 
                                no more stringently than, the 
                                processes, strategies, evidentiary 
                                standards, or other factors used in 
                                applying the limitation with respect to 
                                medical and surgical benefits in the 
                                same classification.
                            ``(iii) Guidance.--The Secretary, in 
                        cooperation with the Secretaries of Health and 
                        Human Services and the Treasury, as 
                        appropriate, shall issue guidance to group 
                        health plans (and health insurance coverage 
                        offered in connection with such a plan) on how 
                        to satisfy the requirements of this section 
                        with respect to making information available to 
                        current and potential participants and 
                        beneficiaries. Such information shall include 
                        certificate of coverage documents and 
                        instruments under which the plan or coverage 
                        involved is administered and operated that 
                        specify, include, or refer to procedures, 
                        formulas, and methodologies applied to 
                        determine a participant or beneficiary's 
                        benefit under the plan or coverage, regardless 
                        of whether such information is contained in a 
                        document designated as the `plan document'. 
                        Such guidance shall include a disclosure of how 
                        the plan or coverage involved has provided that 
                        processes, strategies, evidentiary standards, 
                        and other factors used in applying the NQTL to 
                        mental health or substance use disorder 
                        benefits are comparable to, and applied no more 
                        stringently than, the processes, strategies, 
                        evidentiary standards, or other factors used in 
                        applying the limitation with respect to medical 
                        and surgical benefits in the same 
                        classification.
                            ``(iv) Definitions.--In this paragraph, the 
                        terms `non-quantitative treatment limitations', 
                        `comparable to', and `applied no more 
                        stringently than' have the meanings given such 
                        terms in sections 146 and 147 of title 45, Code 
                        of Federal Regulations (or any successor 
                        regulation).
                    ``(B) Enforcement.--
                            ``(i) Process for complaints.--The 
                        Secretary, in cooperation with the Secretaries 
                        of Health and Human Services and the Treasury, 
                        as appropriate, shall, with respect to group 
                        health plans (and health insurance coverage 
                        offered in connection with such a plan), issue 
                        guidance to clarify the process and timeline 
                        for current and potential participants and 
                        beneficiaries (and authorized representatives 
                        and health care providers of such participants 
                        and beneficiaries) with respect to such plans 
                        (and coverage) to file formal complaints of 
                        such plans (or coverage) being in violation of 
                        this section, including guidance, by plan type, 
                        on the relevant State, regional, and national 
                        offices with which such complaints should be 
                        filed.
                            ``(ii) Authority for public enforcement.--
                        The Secretary, in consultation with the 
                        Secretaries of Labor and the Treasury, shall 
                        make available to the public on the Consumer 
                        Parity Portal website established under section 
                        2726(a)(7) of the Public Health Service Act de-
                        identified information on audits and 
                        investigations of group health plans (and 
                        health insurance coverage offered in connection 
                        with such a plan) conducted under this section.
                            ``(iii) Audits.--
                                    ``(I) Randomized audits.--The 
                                Secretary in cooperation with the 
                                Secretaries of Health and Human 
                                Services and the Treasury, is 
                                authorized to conduct randomized audits 
                                of group health plans (and health 
                                insurance coverage offered in 
                                connection with such a plan) to 
                                determine compliance with this section. 
                                Such audits shall be conducted on no 
                                fewer than twelve plans and coverage 
                                per plan year. Information from such 
                                audits shall be made plainly available 
                                on the Consumer Parity Portal website 
                                established under section 2726(a)(7) of 
                                the Public Health Service Act.
                                    ``(II) Additional audits.--In the 
                                case of a group health plan (and health 
                                insurance coverage offered in 
                                connection with such a plan) with 
                                respect to which any claim has been 
                                filed during a plan year, the Secretary 
                                may audit the books and records of such 
                                plan (or coverage) to determine 
                                compliance with this section. 
                                Information detailing the results of 
                                the audit shall be made available on 
                                the Consumer Parity Portal website 
                                established under section 2726(a)(7) of 
                                the Public Health Service Act.
                            ``(iv) Denial rates.--The Secretary shall 
                        collect information on the rates of and reasons 
                        for denial by group health plans (and health 
                        insurance coverage offered in connection with 
                        such a plan) of claims for outpatient and 
                        inpatient mental health and substance use 
                        disorder services compared to the rates of and 
                        reasons for denial of claims for medical and 
                        surgical services. For the first plan year 
                        beginning at least two years after the date of 
                        the enactment of this paragraph and each 
                        subsequent plan year, the Secretary shall 
                        submit to the Energy and Commerce Committee of 
                        the House of Representatives and the Committee 
                        on Health, Education, Labor, and Pensions of 
                        the Senate, and make plainly available on the 
                        Consumer Parity Portal website under section 
                        2726(a)(7) of the Public Health Service Act, 
                        the information collected under the previous 
                        sentence with respect to the previous plan 
                        year.''.
    (c) Internal Revenue Code of 1986.--Section 9812(a) of the Internal 
Revenue Code of 1986 is amended by adding at the end the following new 
paragraph:
            ``(6) Disclosure and enforcement requirements.--
                    ``(A) Disclosure requirements.--
                            ``(i) Regulations.--Not later than June 30, 
                        2016, the Secretary, in cooperation with the 
                        Secretaries of Health and Human Services and 
                        Labor, as appropriate, shall issue additional 
                        regulations for carrying out this section, 
                        including an explanation of documents that must 
                        be disclosed by plans and issuers, the process 
                        governing such disclosures by plans and 
                        issuers, and analyses that must be conducted by 
                        plans and issuers by a group health plan in 
                        order for such plan to demonstrate compliance 
                        with the provisions of this section.
                            ``(ii) Disclosure requirements.--Documents 
                        required to be disclosed by a group health plan 
                        under clause (i) shall include an annual report 
                        that details the specific analyses performed to 
                        ensure compliance of such plan with the law and 
                        regulations. At a minimum, with respect to the 
                        application of non-quantitative treatment 
                        limitations (in this paragraph referred to as 
                        NQTLs) to benefits under the plan, such report 
                        shall--
                                    ``(I) identify the specific factors 
                                the plan used in performing its NQTL 
                                analysis;
                                    ``(II) identify and define the 
                                specific evidentiary standards relied 
                                on to evaluate the factors;
                                    ``(III) describe how the 
                                evidentiary standards are applied to 
                                each service category for mental 
                                health, substance use disorders, 
                                medical benefits, and surgical 
                                benefits;
                                    ``(IV) disclose the results of the 
                                analyses of the specific evidentiary 
                                standards in each service category; and
                                    ``(V) disclose the specific 
                                findings of the plan in each service 
                                category and the conclusions reached 
                                with respect to whether the processes, 
                                strategies, evidentiary standards, or 
                                other factors used in applying the NQTL 
                                to mental health or substance use 
                                disorder benefits are comparable to, 
                                and applied no more stringently than, 
                                the processes, strategies, evidentiary 
                                standards, or other factors used in 
                                applying the limitation with respect to 
                                medical and surgical benefits in the 
                                same classification.
                            ``(iii) Guidance.--The Secretary, in 
                        cooperation with the Secretaries of Health and 
                        Human Services and Labor, as appropriate, shall 
                        issue guidance to group health plans on how to 
                        satisfy the requirements of this section with 
                        respect to making information available to 
                        current and potential participants and 
                        beneficiaries. Such information shall include 
                        certificate of coverage documents and 
                        instruments under which the plan involved is 
                        administered and operated that specify, 
                        include, or refer to procedures, formulas, and 
                        methodologies applied to determine a 
                        participant or beneficiary's benefit under the 
                        plan, regardless of whether such information is 
                        contained in a document designated as the `plan 
                        document'. Such guidance shall include a 
                        disclosure of how the plan involved has 
                        provided that processes, strategies, 
                        evidentiary standards, and other factors used 
                        in applying the NQTL to mental health or 
                        substance use disorder benefits are comparable 
                        to, and applied no more stringently than, the 
                        processes, strategies, evidentiary standards, 
                        or other factors used in applying the 
                        limitation with respect to medical and surgical 
                        benefits in the same classification.
                            ``(iv) Definitions.--In this paragraph, the 
                        terms `non-quantitative treatment limitations', 
                        `comparable to', and `applied no more 
                        stringently than' have the meanings given such 
                        terms in sections 146 and 147 of title 45, Code 
                        of Federal Regulations (or any successor 
                        regulation).
                    ``(B) Enforcement.--
                            ``(i) Process for complaints.--The 
                        Secretary, in cooperation with the Secretaries 
                        of Health and Human Services and Labor, as 
                        appropriate, shall, with respect to group 
                        health plans, issue guidance to clarify the 
                        process and timeline for current and potential 
                        participants and beneficiaries (and authorized 
                        representatives and health care providers of 
                        such participants and beneficiaries) with 
                        respect to such plans to file formal complaints 
                        of such plans being in violation of this 
                        section, including guidance, by plan type, on 
                        the relevant State, regional, and national 
                        offices with which such complaints should be 
                        filed.
                            ``(ii) Authority for public enforcement.--
                        The Secretary, in consultation with the 
                        Secretaries of Labor and the Treasury, shall 
                        make available to the public on the Consumer 
                        Parity Portal website established under section 
                        2726(a)(7) of the Public Health Service Act de-
                        identified information on audits and 
                        investigations of group health plans conducted 
                        under this section.
                            ``(iii) Audits.--
                                    ``(I) Randomized audits.--The 
                                Secretary in cooperation with the 
                                Secretaries of Health and Human 
                                Services and Labor, is authorized to 
                                conduct randomized audits of group 
                                health plans to determine compliance 
                                with this section. Such audits shall be 
                                conducted on no fewer than twelve plans 
                                per plan year. Information from such 
                                audits shall be made plainly available 
                                on the Consumer Parity Portal website 
                                established under section 2726(a)(7) of 
                                the Public Health Service Act.
                                    ``(II) Additional audits.--In the 
                                case of a group health plan with 
                                respect to which any claim has been 
                                filed during a plan year, the Secretary 
                                may audit the books and records of such 
                                plan to determine compliance with this 
                                section. Information detailing the 
                                results of the audit shall be made 
                                available on the Consumer Parity Portal 
                                website established under section 
                                2726(a)(7) of the Public Health Service 
                                Act.
                            ``(iv) Denial rates.--The Secretary shall 
                        collect information on the rates of and reasons 
                        for denial by group health plans of claims for 
                        outpatient and inpatient mental health and 
                        substance use disorder services compared to the 
                        rates of and reasons for denial of claims for 
                        medical and surgical services. For the first 
                        plan year beginning at least two years after 
                        the date of the enactment of this paragraph and 
                        each subsequent plan year, the Secretary shall 
                        submit to the Energy and Commerce Committee of 
                        the House of Representatives and the Committee 
                        on Health, Education, Labor, and Pensions of 
                        the Senate, and make plainly available on the 
                        Consumer Parity Portal website under section 
                        2726(a)(7) of the Public Health Service Act, 
                        the information collected under the previous 
                        sentence with respect to the previous plan 
                        year.''.
    (d) GAO Study on Mental Health and Substance Use Parity Enforcement 
Efforts.--Not later than one year after the date of enactment of this 
Act, the Comptroller General of the United States, in consultation with 
the Secretary of Health and Human Services, the Secretary of Labor, and 
the Secretary of the Treasury, shall submit to Congress, and make 
plainly available on the Consumer Parity Portal website under paragraph 
(7) of section 2726(a) of the Public Health Service Act (42 U.S.C. 
300gg-26(a)), as added by subsection (a), a report detailing the 
enforcement efforts of the responsible departments and agencies in 
implementing sections 2726 of the Public Health Service Act 42 U.S.C. 
300gg-26), 712 of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1185a), and 9812 of the Internal Revenue Code of 1986, 
including--
            (1) the number of investigations and audits that have been 
        conducted into potential parity violations; and
            (2) details on the investigation, audits, or enforcement 
        action that was carried out as a result of such investigations 
        that would not identify the subject of such investigation or 
        enforcement.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated $2,000,000 for each of fiscal years 2016 through 2020 to 
carry out this section, including the amendments made by this section.
                                 <all>