II 

117TH CONGRESS 

2D SESSION S. 4616 

To amend title XXVII of the Public Health Service Act, the Employee 

Retirement Income Security Act of 1974, and the Internal Revenue 

Code of 1986 to strengthen parity in mental health and substance use 

disorder benefits. 

IN THE SENATE OF THE UNITED STATES 

JULY 26, 2022 

Ms. WARREN (for herself, Ms. BALDWIN, Mr. BLUMENTHAL, Mr. BOOKER, 

Mr. BROWN, Mr. KAINE, Ms. KLOBUCHAR, Mr. LUJA ́N, Mr. MARKEY, 

Mr. MURPHY, Mr. SANDERS, Ms. SMITH, Ms. STABENOW, and Mr. VAN

HOLLEN) introduced the following bill; which was read twice and referred 

to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend title XXVII of the Public Health Service Act, 

the Employee Retirement Income Security Act of 1974, 

and the Internal Revenue Code of 1986 to strengthen 

parity in mental health and substance use disorder benefits. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Behavioral Health Cov5 erage Transparency Act of 2022’’. 


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1 SEC. 2. STRENGTHENING PARITY IN MENTAL HEALTH AND 

2 SUBSTANCE USE DISORDER BENEFITS. 

3 (a) PUBLIC HEALTH SERVICE ACT.—Section 

4 2726(a)(8) of the Public Health Service Act (42 U.S.C. 

5 300gg–26(a)(8)) is amended— 

6 (1) in subparagraph (A), in the matter pre7 ceding clause (i)— 

8 (A) by inserting ‘‘(including entities that 

9 provide administrative services in connection 

10 with a group health plan, such as third party 

11 administrators)’’ after ‘‘insurance coverage’’; 

12 and 

13 (B) by striking ‘‘and, beginning 45 days 

14 after’’ and all that follows through ‘‘upon re15 quest,’’ and inserting ‘‘and submit to the Sec16 retary (or the Secretary of Labor or the Sec17 retary of the Treasury, as applicable), on an 

18 annual basis (and at any other time upon re19 quest of the Secretary), and to the applicable 

20 State authority upon request,’’; 

21 (2) in subparagraph (B)— 

22 (A) in the heading, by striking ‘‘REQUEST’’ 

23 and inserting ‘‘REVIEW’’; 

24 (B) in clause (i)— 


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1 (i) in the heading, by striking ‘‘SUB2 MISSION UPON REQUEST’’ and inserting 

3 ‘‘IN GENERAL’’; 

4 (ii) by striking ‘‘shall request’’ and all 

5 that follows through ‘‘coverage submit’’ 

6 and insert ‘‘shall conduct a review of’’; and 

7 (iii) by striking ‘‘shall request not 

8 fewer than 20’’ and inserting ‘‘shall con9 duct a review of not fewer than 60’’; 

10 (C) in clause (ii)— 

11 (i) in the first sentence, by striking 

12 ‘‘as requested under clause (i)’’ and insert13 ing ‘‘as submitted under such subpara14 graph’’; 

15 (ii) in the first sentence, by striking 

16 ‘‘to be responsive to the request under 

17 clause (i) for’’ and inserting ‘‘to enable’’; 

18 and 

19 (iii) in the second sentence, by strik20 ing ‘‘, as requested under clause (i)’’; 

21 (D) in clause (iii)— 

22 (i) in subclause (I), by striking ‘‘, as 

23 requested under clause (i),’’; and 

24 (ii) by adding at the end of subclause 

25 (II) the following new sentence: ‘‘The preVerDate Sep 11 2014 23:05 Aug 01, 2022 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S4616.IS S4616

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1 ceding sentence shall not apply with re2 spect to disclosures made on or after the 

3 date of the enactment of this sentence.’’; 

4 and 

5 (E) in clause (iv)— 

6 (i) in subclause (I)— 

7 (I) by striking ‘‘requested under 

8 clause (i)’’ and inserting ‘‘reviewed 

9 under clause (i)’’; and 

10 (II) by striking ‘‘after the final 

11 determination by the Secretary de12 scribed in clause (iii)(I)(bb)’’ and in13 serting ‘‘by the Secretary as described 

14 in clause (iii)(I)’’; 

15 (ii) in subclause (II), by striking ‘‘the 

16 comparative analyses requested under 

17 clause (i)’’ and inserting ‘‘such compara18 tive analyses’’; 

19 (iii) in subclause (III), by striking 

20 ‘‘the comparative analyses requested under 

21 clause (i)’’ and inserting ‘‘such compara22 tive analyses’’; 

23 (iv) in subclause (IV)— 

24 (I) by striking ‘‘the comparative 

25 analyses requested under clause (i)’’ 


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1 and inserting ‘‘such comparative anal2 yses’’; and 

3 (II) by striking ‘‘and’’ at the end; 

4 (v) in subclause (V), by striking the 

5 period and inserting a semicolon; and 

6 (vi) by adding at the end the fol7 lowing: 

8 ‘‘(VI) the name of each group 

9 health plan or health insurance issuer 

10 found not to have submitted compara11 tive analyses in accordance with sub12 paragraph (A); 

13 ‘‘(VII) the name of each group 

14 health plan or health insurance issuer 

15 whose comparative analyses were re16 viewed under clause (i) and found not 

17 to have submitted sufficient informa18 tion for the Secretary to review; and 

19 ‘‘(VIII) the name of any plan or 

20 coverage with respect to which a com21 plaint has been submitted under sub22 paragraph (C) and for which a final 

23 review finding has been issued. 

24 The requirements of this clause with re25 spect to plans or issuers shall also apply to 


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1 entities that provide administrative services 

2 in connection with a group health plan, 

3 such as third party administrators, if ap4 plicable.’’; 

5 (3) in subparagraph (C)(i), by striking ‘‘re6 quested’’; and 

7 (4) by adding at the end the following new sub8 paragraphs: 

9 ‘‘(D) AUDIT PROCESS.—Beginning 1 year 

10 after the date of enactment of this subpara11 graph, the Secretary, in cooperation with the 

12 Secretaries of Labor and the Treasury, as ap13 plicable, shall, in addition to conducting reviews 

14 in accordance with subparagraph (B), conduct 

15 randomized audits of group health plans, health 

16 insurance issuers offering group or individual 

17 health insurance coverage, and entities that 

18 provide administrative services in connection 

19 with a group health plan, such as third party 

20 administrators, to determine compliance with 

21 this section. Such audits shall be conducted on 

22 no fewer than 40 plans or coverages per cal23 endar year (not including any reviews con24 ducted under such subparagraph). In addition, 

25 the Secretary may, in cooperation with the SecVerDate Sep 11 2014 23:05 Aug 01, 2022 Jkt 029200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S4616.IS S4616

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1 retaries of Labor and the Treasury, as applica2 ble, and in consultation with the Inspector Gen3 eral of the Department of Health and Human 

4 Services, the Inspector General of the Depart5 ment of Labor, and the Inspector General of 

6 the Department of the Treasury, as applicable, 

7 conduct audits on any such plan or coverage 

8 with respect to which a complaint has been sub9 mitted under subparagraph (E) to determine 

10 compliance with this section. 

11 ‘‘(E) COMPLAINT PROCESS.—Not later 

12 than 6 months after the date of enactment of 

13 this subparagraph, the Secretary, in coopera14 tion with the Secretary of Labor and the Sec15 retary of the Treasury, shall, with respect to 

16 group health plans and health insurance issuers 

17 offering group or individual health insurance 

18 coverage (including entities that provide admin19 istrative services in connection with a group 

20 health plan, such as third party administra21 tors), issue guidance to clarify the process and 

22 timeline for current and potential participants 

23 and beneficiaries (and authorized representa24 tives and health care providers of such partici25 pants and beneficiaries) with respect to such 


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1 plans and coverage to file formal complaints of 

2 such plans or issuers being in violation of this 

3 section, including guidance, by plan type, on the 

4 relevant State, regional, and national offices 

5 with which such complaints should be filed. 

6 ‘‘(F) COVERAGE DISPARITY INFORMA7 TION.—For the first calendar year that begins 

8 on or after the date that is 2 years after the 

9 date of the enactment of this subparagraph, 

10 and for each subsequent calendar year, the Sec11 retary, in cooperation with the Secretaries of 

12 Labor and the Treasury, shall submit to the 

13 Committee on Energy and Commerce of the 

14 House of Representatives and the Committee 

15 on Health, Education, Labor, and Pensions of 

16 the Senate the following information with re17 spect to the preceding calendar year: 

18 ‘‘(i) DENIAL RATES.—Data comparing 

19 the rates of and reasons for denial by 

20 group health plans and health insurance 

21 issuers offering group or individual health 

22 insurance coverage (including entities that 

23 provide administrative services in connec24 tion with a group health plan, such as 

25 third party administrators) of claims for 


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1 mental health benefits, substance use dis2 order benefits, and medical and surgical 

3 benefits, disaggregated by the following 

4 categories: 

5 ‘‘(I) Inpatient, in-network claims. 

6 ‘‘(II) Inpatient, out-of-network 

7 claims. 

8 ‘‘(III) Outpatient, in-network 

9 claims. 

10 ‘‘(IV) Outpatient, out-of-network 

11 claims. 

12 ‘‘(V) Emergency services. 

13 ‘‘(VI) Prescription drug claims. 

14 ‘‘(ii) NETWORK ADEQUACY DATA.— 

15 Data comparing the network adequacy of 

16 group health plans and health insurance 

17 issuers offering group or individual health 

18 insurance coverage (including entities that 

19 provide administrative services in connec20 tion with a group health plan, such as 

21 third party administrators) based on 

22 claims for outpatient and inpatient mental 

23 health benefits, substance use disorder 

24 benefits, and medical and surgical benefits, 

25 including out-of-network utilization rates, 


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1 the number and percentage of in-network 

2 providers accepting new patients, and aver3 age wait times between receiving initial 

4 treatment and diagnosis and follow-up 

5 treatment. 

6 ‘‘(iii) REIMBURSEMENT RATES.—Data 

7 comparing the reimbursement rates of 

8 group health plans and health insurance 

9 issuers offering group or individual health 

10 insurance coverage (including entities that 

11 provide administrative services in connec12 tion with a group health plan, such as 

13 third party administrators) for the 10 

14 most commonly billed mental health serv15 ices, substance use services, and medical 

16 and surgical services, each as a percentage 

17 of rates payable for such services under 

18 title XVIII of the Social Security Act, 

19 disaggregated by the following categories: 

20 ‘‘(I) Inpatient, in-network claims. 

21 ‘‘(II) Inpatient, out-of-network 

22 claims. 

23 ‘‘(III) Outpatient, in-network 

24 claims. 


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1 ‘‘(IV) Outpatient, out-of-network 

2 claims. 

3 ‘‘(V) Emergency services. 

4 ‘‘(VI) Prescription drug claims.’’. 

5 (b) EMPLOYEE RETIREMENT INCOME SECURITY ACT

6 OF 1974.—Section 712(a)(8) of the Employee Retirement 

7 Income Security Act of 1974 (29 U.S.C. 1185a(a)(8)) is 

8 amended— 

9 (1) in subparagraph (A), in the matter pre10 ceding clause (i)— 

11 (A) by inserting ‘‘(including entities that 

12 provide administrative services in connection 

13 with a group health plan, such as third party 

14 administrators)’’ after ‘‘insurance coverage’’; 

15 and 

16 (B) by striking ‘‘and, beginning 45 days 

17 after’’ and all that follows through ‘‘upon re18 quest,’’ and inserting ‘‘and submit to the Sec19 retary (or the Secretary of Health and Human 

20 Services or the Secretary of the Treasury, as 

21 applicable), on an annual basis (and at any 

22 other time upon request of the Secretary),’’; 

23 (2) in subparagraph (B)— 

24 (A) in the heading, by striking ‘‘REQUEST’’ 

25 and inserting ‘‘REVIEW’’; 


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1 (B) in clause (i)— 

2 (i) in the heading, by striking ‘‘SUB3 MISSION UPON REQUEST’’ and inserting 

4 ‘‘IN GENERAL’’; 

5 (ii) by striking ‘‘shall request’’ and all 

6 that follows through ‘‘coverage submit’’ 

7 and insert ‘‘shall conduct a review of’’; and 

8 (iii) by striking ‘‘shall request not 

9 fewer than 20’’ and inserting ‘‘shall con10 duct a review of not fewer than 60’’; 

11 (C) in clause (ii)— 

12 (i) in the first sentence, by striking 

13 ‘‘as requested under clause (i)’’ and insert14 ing ‘‘as submitted under such subpara15 graph’’; 

16 (ii) in the first sentence, by striking 

17 ‘‘to be responsive to the request under 

18 clause (i) for’’ and inserting ‘‘to enable’’; 

19 and 

20 (iii) in the second sentence, by strik21 ing ‘‘, as requested under clause (i)’’; 

22 (D) in clause (iii)— 

23 (i) in subclause (I), by striking ‘‘, as 

24 requested under clause (i),’’; and 


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1 (ii) by adding at the end of subclause 

2 (II) the following new sentence: ‘‘The pre3 ceding sentence shall not apply with re4 spect to disclosures made on or after the 

5 date of the enactment of this sentence.’’; 

6 and 

7 (E) in clause (iv)— 

8 (i) in subclause (I)— 

9 (I) by striking ‘‘requested under 

10 clause (i)’’ and inserting ‘‘reviewed 

11 under clause (i)’’; and 

12 (II) by striking ‘‘after the final 

13 determination by the Secretary de14 scribed in clause (iii)(I)(bb)’’ and in15 serting ‘‘by the Secretary as described 

16 in clause (iii)(I)’’; 

17 (ii) in subclause (II), by striking ‘‘the 

18 comparative analyses requested under 

19 clause (i)’’ and inserting ‘‘such compara20 tive analyses’’; 

21 (iii) in subclause (III), by striking 

22 ‘‘the comparative analyses requested under 

23 clause (i)’’ and inserting ‘‘such compara24 tive analyses’’; 

25 (iv) in subclause (IV)— 


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1 (I) by striking ‘‘the comparative 

2 analyses requested under clause (i)’’ 

3 and inserting ‘‘such comparative anal4 yses’’; and 

5 (II) by striking ‘‘and’’ at the end; 

6 (v) in subclause (V), by striking the 

7 period and inserting a semicolon; and 

8 (vi) by adding at the end the fol9 lowing: 

10 ‘‘(VI) the name of each group 

11 health plan or health insurance issuer 

12 found not to have submitted compara13 tive analyses in accordance with sub14 paragraph (A); 

15 ‘‘(VII) the name of each group 

16 health plan or health insurance issuer 

17 whose comparative analyses were re18 viewed under clause (i) and found not 

19 to have submitted sufficient informa20 tion for the Secretary to review; and 

21 ‘‘(VIII) the name of any plan or 

22 coverage with respect to which a com23 plaint has been submitted under sub24 paragraph (C) and for which a final 

25 review finding has been issued. 


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1 The requirements of this clause with re2 spect to plans or issuers shall also apply to 

3 entities that provide administrative services 

4 in connection with a group health plan, 

5 such as third party administrators, if ap6 plicable.’’; 

7 (3) in subparagraph (C)(i), by striking ‘‘re8 quested’’; and 

9 (4) by adding at the end the following new sub10 paragraphs: 

11 ‘‘(D) AUDIT PROCESS.—Beginning 1 year 

12 after the date of enactment of this subpara13 graph, the Secretary, in cooperation with the 

14 Secretaries of Health and Human Services and 

15 the Treasury, as applicable, shall, in addition to 

16 conducting reviews in accordance with subpara17 graph (B), conduct randomized audits of group 

18 health plans, health insurance issuers offering 

19 group health insurance coverage, and entities 

20 that provide administrative services in connec21 tion with a group health plan, such as third 

22 party administrators, to determine compliance 

23 with this section. Such audits shall be con24 ducted on no fewer than 40 plans or coverages 

25 per calendar year (not including any reviews 


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1 conducted under such subparagraph). In addi2 tion, the Secretary may, in cooperation with the 

3 Secretaries of Health and Human Services and 

4 the Treasury, as applicable, and in consultation 

5 with the Inspector General of the Department 

6 of Health and Human Services, the Inspector 

7 General of the Department of Labor, and the 

8 Inspector General of the Department of the 

9 Treasury, as applicable, conduct audits on any 

10 such plan or coverage with respect to which a 

11 complaint has been submitted under subpara12 graph (E) to determine compliance with this 

13 section. 

14 ‘‘(E) COMPLAINT PROCESS.—Not later 

15 than 6 months after the date of enactment of 

16 this subparagraph, the Secretary, in coopera17 tion with the Secretary of Health and Human 

18 Services and the Secretary of the Treasury, 

19 shall, with respect to group health plans and 

20 health insurance issuers offering group health 

21 insurance coverage (including entities that pro22 vide administrative services in connection with a 

23 group health plan, such as third party adminis24 trators), issue guidance to clarify the process 

25 and timeline for current and potential particiVerDate Sep 11 2014 23:05 Aug 01, 2022 Jkt 029200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\S4616.IS S4616

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1 pants and beneficiaries (and authorized rep2 resentatives and health care providers of such 

3 participants and beneficiaries) with respect to 

4 such plans and coverage to file formal com5 plaints of such plans or issuers being in viola6 tion of this section, including guidance, by plan 

7 type, on the relevant State, regional, and na8 tional offices with which such complaints should 

9 be filed. 

10 ‘‘(F) COVERAGE DISPARITY INFORMA11 TION.—For the first calendar year that begins 

12 on or after the date that is 2 years after the 

13 date of the enactment of this subparagraph, 

14 and for each subsequent calendar year, the Sec15 retary, in cooperation with the Secretaries of 

16 Health and Human Services and the Treasury, 

17 shall submit to the Committee on Energy and 

18 Commerce of the House of Representatives and 

19 the Committee on Health, Education, Labor, 

20 and Pensions of the Senate the following infor21 mation with respect to the preceding calendar 

22 year: 

23 ‘‘(i) DENIAL RATES.—Data comparing 

24 the rates of and reasons for denial by 

25 group health plans and health insurance 


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1 issuers offering group health insurance 

2 coverage (including entities that provide 

3 administrative services in connection with 

4 a group health plan, such as third party 

5 administrators) of claims for mental health 

6 benefits, substance use disorder benefits, 

7 and medical and surgical benefits, 

8 disaggregated by the following categories: 

9 ‘‘(I) Inpatient, in-network claims. 

10 ‘‘(II) Inpatient, out-of-network 

11 claims. 

12 ‘‘(III) Outpatient, in-network 

13 claims. 

14 ‘‘(IV) Outpatient, out-of-network 

15 claims. 

16 ‘‘(V) Emergency services. 

17 ‘‘(VI) Prescription drug claims. 

18 ‘‘(ii) NETWORK ADEQUACY DATA.— 

19 Data comparing the network adequacy of 

20 group health plans and health insurance 

21 issuers offering group health insurance 

22 coverage (including entities that provide 

23 administrative services in connection with 

24 a group health plan, such as third party 

25 administrators) based on claims for outVerDate Sep 11 2014 23:05 Aug 01, 2022 Jkt 029200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\S4616.IS S4616

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1 patient and inpatient mental health bene2 fits, substance use disorder benefits, and 

3 medical and surgical benefits, including 

4 out-of-network utilization rates, the num5 ber and percentage of in-network providers 

6 accepting new patients, and average wait 

7 times between receiving initial treatment 

8 and diagnosis and follow-up treatment. 

9 ‘‘(iii) REIMBURSEMENT RATES.—Data 

10 comparing the reimbursement rates of 

11 group health plans and health insurance 

12 issuers offering group health insurance 

13 coverage (including entities that provide 

14 administrative services in connection with 

15 a group health plan, such as third party 

16 administrators) for the 10 most commonly 

17 billed mental health services, substance use 

18 services, and medical and surgical services, 

19 each as a percentage of rates payable for 

20 such services under title XVIII of the So21 cial Security Act, disaggregated by the fol22 lowing categories: 

23 ‘‘(I) Inpatient, in-network claims. 

24 ‘‘(II) Inpatient, out-of-network 

25 claims. 


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1 ‘‘(III) Outpatient, in-network 

2 claims. 

3 ‘‘(IV) Outpatient, out-of-network 

4 claims. 

5 ‘‘(V) Emergency services. 

6 ‘‘(VI) Prescription drug claims.’’. 

7 (c) INTERNAL REVENUE CODE OF 1986.—Section 

8 9812(a)(8) of the Internal Revenue Code of 1986 is 

9 amended— 

10 (1) in subparagraph (A), in the matter pre11 ceding clause (i)— 

12 (A) by inserting ‘‘(including entities that 

13 provide administrative services in connection 

14 with a group health plan, such as third party 

15 administrators)’’ after ‘‘In the case of a group 

16 health plan’’; and 

17 (B) by striking ‘‘and, beginning 45 days 

18 after’’ and all that follows through ‘‘upon re19 quest,’’ and inserting ‘‘and submit to the Sec20 retary (or the Secretary of Health and Human 

21 Services or the Secretary of Labor, as applica22 ble), on an annual basis (and at any other time 

23 upon request of the Secretary),’’; 

24 (2) in subparagraph (B)— 


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1 (A) in the heading, by striking ‘‘REQUEST’’ 

2 and inserting ‘‘REVIEW’’; 

3 (B) in clause (i)— 

4 (i) in the heading, by striking ‘‘SUB5 MISSION UPON REQUEST’’ and inserting 

6 ‘‘IN GENERAL’’; 

7 (ii) by striking ‘‘shall request’’ and all 

8 that follows through ‘‘plan submit’’ and in9 sert ‘‘shall conduct a review of’’; and 

10 (iii) by striking ‘‘shall request not 

11 fewer than 20’’ and inserting ‘‘shall con12 duct a review of not fewer than 60’’; 

13 (C) in clause (ii)— 

14 (i) in the first sentence, by striking 

15 ‘‘as requested under clause (i)’’ and insert16 ing ‘‘as submitted under such subpara17 graph’’; 

18 (ii) in the first sentence, by striking 

19 ‘‘to be responsive to the request under 

20 clause (i) for’’ and inserting ‘‘to enable’’; 

21 and 

22 (iii) in the second sentence, by strik23 ing ‘‘, as requested under clause (i)’’; 

24 (D) in clause (iii)— 


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1 (i) in subclause (I), by striking ‘‘, as 

2 requested under clause (i),’’; and 

3 (ii) by adding at the end of subclause 

4 (II) the following new sentence: ‘‘The pre5 ceding sentence shall not apply with re6 spect to disclosures made on or after the 

7 date of the enactment of this sentence.’’; 

8 and 

9 (E) in clause (iv)— 

10 (i) in subclause (I)— 

11 (I) by striking ‘‘requested under 

12 clause (i)’’ and inserting ‘‘reviewed 

13 under clause (i)’’; and 

14 (II) by striking ‘‘after the final 

15 determination by the Secretary de16 scribed in clause (iii)(I)(bb)’’ and in17 serting ‘‘by the Secretary as described 

18 in clause (iii)(I)’’; 

19 (ii) in subclause (II), by striking ‘‘the 

20 comparative analyses requested under 

21 clause (i)’’ and inserting ‘‘such compara22 tive analyses’’; 

23 (iii) in subclause (III), by striking 

24 ‘‘the comparative analyses requested under 


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1 clause (i)’’ and inserting ‘‘such compara2 tive analyses’’; 

3 (iv) in subclause (IV)— 

4 (I) by striking ‘‘the comparative 

5 analyses requested under clause (i)’’ 

6 and inserting ‘‘such comparative anal7 yses’’; and 

8 (II) by striking ‘‘and’’ at the end; 

9 (v) in subclause (V), by striking the 

10 period and inserting a semicolon; and 

11 (vi) by adding at the end the fol12 lowing: 

13 ‘‘(VI) the name of each group 

14 health plan found not to have sub15 mitted comparative analyses in ac16 cordance with subparagraph (A); 

17 ‘‘(VII) the name of each group 

18 health plan whose comparative anal19 yses were reviewed under clause (i) 

20 and found not to have submitted suf21 ficient information for the Secretary 

22 to review; and 

23 ‘‘(VIII) the name of any plan 

24 with respect to which a complaint has 

25 been submitted under subparagraph 


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1 (C) and for which a final review find2 ing has been issued. 

3 The requirements of this clause with re4 spect to plans shall also apply to entities 

5 that provide administrative services in con6 nection with a group health plan, such as 

7 third party administrators, if applicable.’’; 

8 (3) in subparagraph (C)(i), by striking ‘‘re9 quested’’; and 

10 (4) by adding at the end the following new sub11 paragraphs: 

12 ‘‘(D) AUDIT PROCESS.—Beginning 1 year 

13 after the date of enactment of this subpara14 graph, the Secretary, in cooperation with the 

15 Secretaries of Health and Human Services and 

16 Labor, as applicable, shall, in addition to con17 ducting reviews in accordance with subpara18 graph (B), conduct randomized audits of group 

19 health plans and entities that provide adminis20 trative services in connection with a group 

21 health plan, such as third party administrators, 

22 to determine compliance with this section. Such 

23 audits shall be conducted on no fewer than 40 

24 plans per calendar year (not including any re25 views conducted under such subparagraph). In 


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1 addition, the Secretary may, in cooperation with 

2 the Secretaries of Health and Human Services 

3 and Labor, as applicable, and in consultation 

4 with the Inspector General of the Department 

5 of Health and Human Services, the Inspector 

6 General of the Department of Labor, and the 

7 Inspector General of the Department of the 

8 Treasury, as applicable, conduct audits on any 

9 such plan with respect to which a complaint has 

10 been submitted under subparagraph (E) to de11 termine compliance with this section. 

12 ‘‘(E) COMPLAINT PROCESS.—Not later 

13 than 6 months after the date of enactment of 

14 this subparagraph, the Secretary, in coopera15 tion with the Secretary of Health and Human 

16 Services and the Secretary of Labor, shall, with 

17 respect to group health plans (including entities 

18 that provide administrative services in connec19 tion with a group health plan, such as third 

20 party administrators), issue guidance to clarify 

21 the process and timeline for current and poten22 tial participants and beneficiaries (and author23 ized representatives and health care providers 

24 of such participants and beneficiaries) with re25 spect to such plans to file formal complaints of 


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1 such plans being in violation of this section, in2 cluding guidance, by plan type, on the relevant 

3 State, regional, and national offices with which 

4 such complaints should be filed. 

5 ‘‘(F) COVERAGE DISPARITY INFORMA6 TION.—For the first calendar year that begins 

7 on or after the date that is 2 years after the 

8 date of the enactment of this subparagraph, 

9 and for each subsequent calendar year, the Sec10 retary, in cooperation with the Secretaries of 

11 Health and Human Services and Labor, shall 

12 submit to the Committee on Energy and Com13 merce of the House of Representatives and the 

14 Committee on Health, Education, Labor, and 

15 Pensions of the Senate the following informa16 tion with respect to the preceding calendar 

17 year: 

18 ‘‘(i) DENIAL RATES.—Data comparing 

19 the rates of and reasons for denial by 

20 group health plans (including entities that 

21 provide administrative services in connec22 tion with a group health plan, such as 

23 third party administrators) of claims for 

24 mental health benefits, substance use dis25 order benefits, and medical and surgical 


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1 benefits, disaggregated by the following 

2 categories: 

3 ‘‘(I) Inpatient, in-network claims. 

4 ‘‘(II) Inpatient, out-of-network 

5 claims. 

6 ‘‘(III) Outpatient, in-network 

7 claims. 

8 ‘‘(IV) Outpatient, out-of-network 

9 claims. 

10 ‘‘(V) Emergency services. 

11 ‘‘(VI) Prescription drug claims. 

12 ‘‘(ii) NETWORK ADEQUACY DATA.— 

13 Data comparing the network adequacy of 

14 group health plans (including entities that 

15 provide administrative services in connec16 tion with a group health plan, such as 

17 third party administrators) based on 

18 claims for outpatient and inpatient mental 

19 health benefits, substance use disorder 

20 benefits, and medical and surgical benefits, 

21 including out-of-network utilization rates, 

22 the number and percentage of in-network 

23 providers accepting new patients, and aver24 age wait times between receiving initial 


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1 treatment and diagnosis and follow-up 

2 treatment. 

3 ‘‘(iii) REIMBURSEMENT RATES.—Data 

4 comparing the reimbursement rates of 

5 group health plans (including entities that 

6 provide administrative services in connec7 tion with a group health plan, such as 

8 third party administrators) for the 10 

9 most commonly billed mental health serv10 ices, substance use services, and medical 

11 and surgical services, each as a percentage 

12 of rates payable for such services under 

13 title XVIII of the Social Security Act, 

14 disaggregated by the following categories: 

15 ‘‘(I) Inpatient, in-network claims. 

16 ‘‘(II) Inpatient, out-of-network 

17 claims. 

18 ‘‘(III) Outpatient, in-network 

19 claims. 

20 ‘‘(IV) Outpatient, out-of-network 

21 claims. 

22 ‘‘(V) Emergency services. 

23 ‘‘(VI) Prescription drug claims.’’. 


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1 SEC. 3. CONSUMER PARITY UNIT FOR MENTAL HEALTH 

2 AND SUBSTANCE USE DISORDER PARITY VIO3 LATIONS. 

4 (a) DEFINITIONS.—In this section: 

5 (1) APPLICABLE STATE AUTHORITY.—The term 

6 ‘‘applicable State authority’’ has the meaning given 

7 the term in section 2791 of the Public Health Serv8 ice Act (42 U.S.C. 300gg–91). 

9 (2) COVERED PLAN.—The term ‘‘covered plan’’ 

10 means any creditable coverage that is subject to any 

11 of the mental health parity laws described in para12 graph (4). 

13 (3) CREDITABLE COVERAGE.—The term ‘‘cred14 itable coverage’’ has the meaning given the term in 

15 section 2704(c) of the Public Health Service Act (42 

16 U.S.C. 300gg–3(c)). 

17 (4) MENTAL HEALTH PARITY LAW.—The term 

18 ‘‘mental health parity law’’ means— 

19 (A) section 2726 of the Public Health 

20 Service Act (42 U.S.C. 300gg–26); 

21 (B) section 712 of the Employee Retire22 ment Income Security Act of 1974 (29 U.S.C. 

23 1185a); 

24 (C) section 9812 of the Internal Revenue 

25 Code of 1986; or 


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1 (D) any other Federal law that applies the 

2 requirements under any of the sections de3 scribed in subparagraph (A), (B), or (C), or re4 quirements that are substantially similar to the 

5 requirements under any such section, as deter6 mined by the Secretary, to creditable coverage. 

7 (5) SECRETARY.—The term ‘‘Secretary’’ means 

8 the Secretary of Health and Human Services. 

9 (6) SPECIFIED COVERED PLAN.—The term 

10 ‘‘specified covered plan’’ means a covered plan that 

11 is any of the following: 

12 (A) A group health plan or group or indi13 vidual health insurance coverage (as such terms 

14 are defined in section 2791 of the Public 

15 Health Service Act (42 U.S.C. 300gg–91)). 

16 (B) A Medicare Advantage plan offered 

17 under part C of title XVIII of the Social Secu18 rity Act (42 U.S.C. 1395w–21 et seq.). 

19 (C) A State plan (or waiver of such plan) 

20 under title XIX of the Social Security Act (42 

21 U.S.C. 1396 et seq.). 

22 (D) A plan offered under the program es23 tablished under chapter 89 of title 5, United 

24 States Code. 


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1 (b) ESTABLISHMENT.—Not later than 6 months after 

2 the date of enactment of this Act, the Secretary, in con3 sultation with the Secretary of Labor, the Secretary of the 

4 Treasury, and the heads of any other applicable agencies, 

5 shall establish a consumer parity unit with functions that 

6 include— 

7 (1) facilitating the centralized collection of, 

8 monitoring of, and response to consumer complaints 

9 (including provider complaints) regarding violations 

10 of mental health parity laws through developing and 

11 administering, in accordance with subsection (d)— 

12 (A) a single, toll-free telephone number; 

13 and 

14 (B) a public website portal, which may in15 clude enhancing a website portal in existence on 

16 the date of enactment of this Act; and 

17 (2) providing information to health care con18 sumers regarding the disclosure requirements and 

19 enforcement under section 2726(a)(8) of the Public 

20 Health Service Act (42 U.S.C. 300gg–26(a)(8)), sec21 tion 712(a)(8) of the Employee Retirement Income 

22 Security Act of 1974 (29 U.S.C. 1185a(a)(8)), and 

23 section 9812(a)(8) of the Internal Revenue Code of 

24 1986. 


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1 (c) WEBSITE PORTAL.—The Secretary, in consulta2 tion with the Secretary of Labor, the Secretary of the 

3 Treasury, and the heads of any other applicable agencies, 

4 shall make available on the website portal established 

5 under subsection (b)(1)(B)— 

6 (1) any guidance and any reports issued by the 

7 Secretary, the Secretary of Labor, or the Secretary 

8 of the Treasury, under section 2726 of the Public 

9 Health Service Act (42 U.S.C. 300gg–26), section 

10 712 of the Employee Retirement Income Security 

11 Act of 1974 (29 U.S.C. 1185a), or section 9812 of 

12 the Internal Revenue Code of 1986, respectively; 

13 (2) any information obtained under subsection 

14 (b)(1) that it is in the public interest to disclose, 

15 through aggregated reported or other appropriate 

16 formats designed to protect confidential information 

17 in accordance with subsection (g); and 

18 (3) information on the results of, or progress 

19 on, any concluded or ongoing audits or investiga20 tions of the Secretary, the Secretary of Labor, or the 

21 Secretary of the Treasury, as applicable, under such 

22 section 2726, 712, or 9812, respectively, including 

23 the identity of each group health plan or health in24 surance issuer (including entities that provide ad25 ministrative services in connection with a group 


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•S 4616 IS

1 health plan, such as third party administrators) 

2 that— 

3 (A) was the subject of a concluded audit or 

4 investigation; or 

5 (B) that is the subject of an ongoing audit 

6 or investigation and which was found, pursuant 

7 to such audit or investigation, not to have sub8 mitted NQTL analyses in accordance with such 

9 sections (or to have submitted incomplete 

10 NQTL analyses). 

11 (d) RESPONSE TO CONSUMER COMPLAINTS AND IN12 QUIRIES.— 

13 (1) TIMELY RESPONSE TO CONSUMERS.—The 

14 Secretary, in consultation with the Secretary of 

15 Labor, the Secretary of the Treasury, and the heads 

16 of any other applicable agencies, shall establish rea17 sonable procedures for the consumer parity unit es18 tablished under this section to provide a response (in 

19 writing if appropriate) within 90 days to consumers 

20 regarding complaints received by the unit against, or 

21 inquiries concerning, a covered plan, at the discre22 tion of the applicable agency, which shall at min23 imum include— 

24 (A) steps that have been taken by the ap25 propriate State or Federal enforcement agency 


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1 in response to the complaint or inquiry of the 

2 consumer; 

3 (B) in the case such complaint relates to 

4 a specified covered plan, any responses received 

5 by the appropriate State or Federal enforce6 ment agency from the covered plan; 

7 (C) any follow-up actions or planned fol8 low-up actions by the appropriate State or Fed9 eral enforcement agency in response to the com10 plaint or inquiry of the consumer; and 

11 (D) contact information of the appropriate 

12 enforcement agency for the consumer to obtain 

13 additional information on the complaint or in14 quiry. 

15 (2) TIMELY RESPONSE TO REGULATORS.—A 

16 specified covered plan shall provide a response (in 

17 writing if appropriate) within 7 days to the appro18 priate State or Federal enforcement agency having 

19 jurisdiction over such plan (or, in the case such plan 

20 is a State plan (or wavier of such plan) under title 

21 XIX of the Social Security Act (42 U.S.C. 1396 et 

22 seq.), to the Secretary of Health and Human Serv23 ices) concerning a consumer complaint or inquiry 

24 submitted to the consumer parity unit established 

25 under this section including— 


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1 (A) steps that have been taken by the plan 

2 to respond to the complaint or inquiry of the 

3 consumer; 

4 (B) any responses received by the plan 

5 from the consumer; and 

6 (C) follow-up actions or planned follow-up 

7 actions by the plan in response to the complaint 

8 or inquiry of the consumer. 

9 (3) PROVISION OF INFORMATION TO CON10 SUMERS.— 

11 (A) IN GENERAL.—A covered plan shall 

12 comply with a consumer request for information 

13 in the control or possession of such covered 

14 plan concerning the coverage the consumer ob15 tained from such covered plan within 7 days of 

16 receipt of such request. 

17 (B) EXCEPTIONS.—Notwithstanding sub18 paragraph (A), a covered plan, and any agency 

19 or entity having jurisdiction over a covered 

20 plan, may not be required by this paragraph to 

21 make available to the consumer any information 

22 required to be kept confidential by any other 

23 provision of law. 

24 (4) ENFORCEMENT.— 


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1 (A) PRIVATE INSURANCE.—The provisions 

2 of paragraphs (2) and (3) shall apply to group 

3 health plans and group and individual health 

4 insurance coverage (as such terms are defined 

5 in section 2791 of the Public Health Service 

6 Act (42 U.S.C. 300gg–91)) as if such provi7 sions were included in part D of title XXVII of 

8 such Act (42 U.S.C. 300g–111 et seq.), part 7 

9 of title I of the Employee Retirement Act of 

10 1974 (29 U.S.C. 1181 et seq.), and chapter 

11 100 of the Internal Revenue Code of 1986. 

12 (B) OTHER SPECIFIED COVERED PLANS.— 

13 (i) MEDICARE ADVANTAGE PLANS.— 

14 Section 1852 of the Social Security Act 

15 (42 U.S.C. 1395w–22) is amended by add16 ing at the end the following new section: 

17 ‘‘(o) APPLICATION OF CERTAIN MENTAL HEALTH

18 PARITY COMPLAINT REQUIREMENTS.—An MA plan shall 

19 comply with the requirements of paragraphs (2) and (3) 

20 of section 3(d) of the Behavioral Health Coverage Trans21 parency Act of 2022.’’. 

22 (ii) MEDICAID.—Section 1902(a) of 

23 the Social Security Act (42 U.S.C. 

24 1396a(a)) is amended— 


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1 (I) in paragraph (86), by striking 

2 ‘‘; and’’ at the end; 

3 (II) in paragraph (87)(D), by 

4 striking the period and inserting ‘‘; 

5 and’’; and 

6 (III) by inserting after paragraph 

7 (87) the following new paragraph: 

8 ‘‘(88) provide for compliance with the provi9 sions of paragraphs (2) and (3) of section 3(d) of 

10 the Behavioral Health Coverage Transparency Act 

11 of 2022.’’. 

12 (C) OTHER COVERED PLANS.—In the case 

13 of a covered plan that is not a specified covered 

14 plan, the Federal agency charged with the ad15 ministration or supervision of such plan shall 

16 ensure that such plan complies with the provi17 sions of paragraph (3). 

18 (e) REPORTS.— 

19 (1) IN GENERAL.—Not later than December 31 

20 of each year, the Secretary, in consultation with the 

21 Secretary of Labor, the Secretary of the Treasury, 

22 and the heads of any other applicable agencies, shall 

23 submit a report to Congress on the complaints re24 ceived by the consumer parity unit established under 


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•S 4616 IS

1 this section in the prior year regarding covered 

2 plans. 

3 (2) CONTENTS.—Each such report shall include 

4 information and analysis about complaint numbers, 

5 complaint types, and, where applicable, information 

6 about the resolution of complaints, including the 

7 identity of the group health plan or health insurance 

8 issuer that is the subject of such a complaint. 

9 (3) CONSUMER PARITY UNIT POSTING.—The 

10 Secretary shall submit such reports to the consumer 

11 parity unit established under this section, and such 

12 unit shall post the reports on the website portal es13 tablished under subsection (b)(1)(B). 

14 (f) DATA SHARING.—Subject to any applicable stand15 ards for Federal or State agencies with respect to pro16 tecting personally identifiable information and data secu17 rity and integrity, including the regulations under part 2 

18 of title 42, Code of Federal Regulations— 

19 (1) the consumer parity unit established under 

20 this section shall share consumer complaint informa21 tion with the Secretary, and the head of any other 

22 applicable Federal or State agency; and 

23 (2) the Secretary, and the head of any other 

24 applicable Federal or State agency, shall share data 


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•S 4616 IS

1 relating to consumer complaints regarding covered 

2 plans with such unit. 

3 (g) PRIVACY CONSIDERATIONS.— 

4 (1) IN GENERAL.—In carrying out this section, 

5 the consumer parity unit established under this sec6 tion and the Secretary, in consultation with the Sec7 retary of Labor, the Secretary of the Treasury, and 

8 the head of any other applicable agency, shall take 

9 measures to ensure that proprietary, personal, or 

10 confidential consumer information that is protected 

11 from public disclosure under section 552(b) or 552a 

12 of title 5, United States Code, or any other provision 

13 of law, is not made public under this section. 

14 (2) EXCEPTIONS.—The consumer parity unit 

15 established under this section may not obtain from 

16 a covered plan any personally identifiable informa17 tion about a consumer from the records of the cov18 ered plan, except— 

19 (A) if the records are reasonably described 

20 in a request by the consumer parity unit estab21 lished under this section, and the consumer pro22 vides appropriate consent for the disclosure and 

23 use of such information by the covered plan to 

24 such unit; or 


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1 (B) as may be specifically permitted or re2 quired under other applicable provisions of law, 

3 including the regulations under part 2 of title 

4 42, Code of Federal Regulations. 

5 (h) COLLABORATION.— 

6 (1) AGREEMENTS WITH OTHER AGENCIES.— 

7 The Secretary, the Secretary of Labor, the Secretary 

8 of the Treasury, and the heads of any other applica9 ble agencies, shall enter into a memorandum of un10 derstanding with any affected Federal regulatory 

11 agency regarding procedures by which any covered 

12 plan, and any other agency having jurisdiction over 

13 a covered plan, shall comply with this section. 

14 (2) AGREEMENTS WITH STATES.—To the ex15 tent practicable, an applicable State authority may 

16 receive appropriate complaints from the consumer 

17 parity unit established under this section, if— 

18 (A) the applicable State authority has the 

19 functional capacity to receive calls or electronic 

20 reports routed by the unit; 

21 (B) the applicable State authority has sat22 isfied any conditions of participation that the 

23 unit may establish, including treatment of per24 sonally identifiable information and sharing of 


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1 information on complaint resolution or related 

2 compliance procedures and resources; and 

3 (C) participation by the applicable State 

4 authority includes measures necessary to pro5 tect personally identifiable information in ac6 cordance with standards that apply to Federal 

7 agencies with respect to protecting personally 

8 identifiable information and data security and 

9 integrity. 

10 (3) ASSISTANCE TO STATES.—The Secretary, 

11 the Secretary of Labor, the Secretary of the Treas12 ury, and the heads of any other applicable agencies, 

13 shall provide assistance to States to increase the ca14 pacity of State governments to work with the Fed15 eral parity unit under this section, including through 

16 the provision of training and technical assistance, 

17 and identification of violations of mental health and 

18 substance use disorder parity protections. 

19 (i) FUNDING.— 

20 (1) INITIAL FUNDING.—There is hereby appro21 priated to the Secretary, out of any funds in the 

22 Treasury not otherwise appropriated, $30,000,000 

23 for the first fiscal year for which this section applies 

24 to carry out this section. Such amount shall remain 

25 available until expended. 


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1 (2) AUTHORIZATION FOR SUBSEQUENT

2 YEARS.—There is authorized to be appropriated to 

3 the Secretary for each fiscal year following the fiscal 

4 year described in paragraph (1), such sums as may 

5 be necessary to carry out this section. 

6 SEC. 4. GRANTS FOR HEALTH INSURANCE INFORMATION 

7 CONCERNING MENTAL HEALTH AND SUB8 STANCE USE DISORDER BENEFITS. 

9 (a) IN GENERAL.—The Secretary of Health and 

10 Human Services (referred to in this section as the ‘‘Sec11 retary’’) shall award grants to States to enable such 

12 States (or the Exchanges established under the Patient 

13 Protection and Affordable Care Act (Public Law 111– 

14 148) operating in such States) to establish, expand, or 

15 provide support for— 

16 (1) offices of health insurance consumer assist17 ance; or 

18 (2) health insurance ombudsman programs, 

19 in order to enable such offices and programs to carry out 

20 the activities described in subsection (c). 

21 (b) ELIGIBILITY.— 

22 (1) IN GENERAL.—To be eligible to receive a 

23 grant, a State shall designate an independent office 

24 of health insurance consumer assistance, or an om25 budsman, that, directly or in coordination with State 


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1 private and public health insurance regulators and 

2 consumer assistance organizations, receives and re3 sponds to inquiries and complaints concerning health 

4 insurance coverage with respect to Federal health in5 surance requirements and under State law relating 

6 to mental health or substance use disorder benefits. 

7 (2) CRITERIA.—A State that receives a grant 

8 under this section shall comply with criteria estab9 lished by the Secretary for carrying out activities 

10 under such grant. 

11 (c) USE OF FUNDS.—Funds received from a grant 

12 awarded under this section shall be used by an office of 

13 health insurance consumer assistance or health insurance 

14 ombudsman described in subsection (a) to— 

15 (1) assist with the filing of complaints and ap16 peals, including filing appeals with the internal ap17 peal or grievance process of the group health plan or 

18 health insurance issuer, Medicaid program, and 

19 Children’s Health Insurance Program involved, re20 lating to mental health or substance use disorder 

21 benefits, and providing information about the exter22 nal appeal process; 

23 (2) collect, track, and quantify problems and in24 quiries encountered by consumers; 


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1 (3) educate consumers on their rights and re2 sponsibilities with respect to group health plans and 

3 health insurance coverage, Medicaid, and Children’s 

4 Health Insurance Program relating to mental health 

5 or substance use disorder benefits; 

6 (4) assist consumers with enrollment in a group 

7 health plan or health insurance coverage, Medicaid, 

8 and the Children’s Health Insurance Program by 

9 providing information, referral, and assistance; and 

10 (5) assist consumers in resolving problems with 

11 obtaining premium tax credits under section 36B of 

12 the Internal Revenue Code of 1986 by providing in13 formation, referral, and assistance. 

14 (d) DATA COLLECTION.—As a condition of receiving 

15 a grant under subsection (a), an office of health insurance 

16 consumer assistance or ombudsman program shall be re17 quired to collect and report data to the Secretary and 

18 State public and private health insurance regulators on 

19 the types of problems and inquiries encountered by con20 sumers relating to mental health or substance use disorder 

21 benefits. The Secretary shall utilize such data to identify 

22 areas where more enforcement action is necessary and 

23 shall share such information with State insurance regu24 lators, the Secretary of Labor, and the Secretary of the 


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1 Treasury for use in the enforcement activities of such 

2 agencies. 

3 (e) FUNDING.— 

4 (1) INITIAL FUNDING.—There is hereby appro5 priated to the Secretary, out of any funds in the 

6 Treasury not otherwise appropriated, $25,000,000 

7 for the first fiscal year for which this section applies 

8 to carry out this section. Such amount shall remain 

9 available until expended. 

10 (2) AUTHORIZATION FOR SUBSEQUENT

11 YEARS.—There is authorized to be appropriated to 

12 the Secretary for each fiscal year following the fiscal 

13 year described in paragraph (1), such sums as may 

14 be necessary to carry out this section. 

Æ 


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