I 

108TH CONGRESS 

1ST SESSION H. R. 2256

To amend the Employee Retirement Income Security Act of 1974, Public 

Health Service Act, and the Internal Revenue Code of 1986 to provide 

parity with respect to substance abuse treatment benefits under group 

health plans and health insurance coverage. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 22, 2003

Mr. RAMSTAD 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 amend the Employee Retirement Income Security Act 

of 1974, Public Health Service Act, and the Internal 

Revenue Code of 1986 to provide parity with respect 

to substance abuse treatment benefits under group health 

plans and health insurance coverage.

1 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 ‘‘Help Expand Access 

5 to Recovery and Treatment (HEART) Act of 2003’’. 
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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) Substance abuse, if left untreated, is a med4 ical emergency and a private and public health cri5 sis. 

6 (2) Nothing in this Act should be construed as 

7 prohibiting application of the concept of parity to 

8 substance abuse treatment provided by faith-based 

9 treatment providers. 

10 SEC. 3. PARITY IN SUBSTANCE ABUSE TREATMENT BENE11 FITS. 

12 (a) GROUP HEALTH PLANS.—

13 (1) PUBLIC HEALTH SERVICE ACT AMEND14 MENTS.—

15 (A) IN GENERAL.—Subpart 2 of part A of 

16 title XXVII of the Public Health Service Act is 

17 amended by adding at the end the following 

18 new section: 

19 ‘‘SEC. 2707. PARITY IN THE APPLICATION OF TREATMENT 

20 LIMITATIONS AND FINANCIAL REQUIRE21 MENTS TO SUBSTANCE ABUSE TREATMENT 

22 BENEFITS. 

23 ‘‘(a) IN GENERAL.—In the case of a group health 

24 plan (or health insurance coverage offered in connection 

25 with such a plan) that provides both medical and surgical 

26 benefits and substance abuse treatment benefits, the plan 
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1 or coverage shall not impose treatment limitations or fi2 nancial requirements on the substance abuse treatment 

3 benefits unless similar limitations or requirements are im4 posed for medical and surgical benefits. 

5 ‘‘(b) CONSTRUCTION.—Nothing in this section shall 

6 be construed—

7 ‘‘(1) as requiring a group health plan (or health 

8 insurance coverage offered in connection with such a 

9 plan) to provide any substance abuse treatment ben10 efits; or 

11 ‘‘(2) to prevent a group health plan or a health 

12 insurance issuer offering group health insurance cov13 erage from negotiating the level and type of reim14 bursement with a provider for care provided in ac15 cordance with this section. 

16 ‘‘(c) EXEMPTIONS.—

17 ‘‘(1) SMALL EMPLOYER EXEMPTION.—

18 ‘‘(A) IN GENERAL.—This section shall not 

19 apply to any group health plan (and group 

20 health insurance coverage offered in connection 

21 with a group health plan) for any plan year of 

22 a small employer. 

23 ‘‘(B) SMALL EMPLOYER.—For purposes of 

24 subparagraph (A), the term ‘small employer’ 

25 means, in connection with a group health plan 
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1 with respect to a calendar year and a plan year, 

2 an employer who employed an average of at 

3 least 2 but not more than 50 employees on 

4 business days during the preceding calendar 

5 year and who employs at least 2 employees on 

6 the first day of the plan year. 

7 ‘‘(C) APPLICATION OF CERTAIN RULES IN

8 DETERMINATION OF EMPLOYER SIZE.—For 

9 purposes of this paragraph—

10 ‘‘(i) APPLICATION OF AGGREGATION

11 RULE FOR EMPLOYERS.—Rules similar to 

12 the rules under subsections (b), (c), (m), 

13 and (o) of section 414 of the Internal Rev14 enue Code of 1986 shall apply for purposes 

15 of treating persons as a single employer. 

16 ‘‘(ii) EMPLOYERS NOT IN EXISTENCE

17 IN PRECEDING YEAR.—In the case of an 

18 employer which was not in existence 

19 throughout the preceding calendar year, 

20 the determination of whether such em21 ployer is a small employer shall be based 

22 on the average number of employees that 

23 it is reasonably expected such employer 

24 will employ on business days in the current 

25 calendar year. 
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1 ‘‘(iii) PREDECESSORS.—Any reference 

2 in this paragraph to an employer shall in3 clude a reference to any predecessor of 

4 such employer. 

5 ‘‘(2) INCREASED COST EXEMPTION.—This sec6 tion shall not apply with respect to a group health 

7 plan (or health insurance coverage offered in connec8 tion with a group health plan) if the application of 

9 this section to such plan (or to such coverage) re10 sults in an increase in the cost under the plan (or 

11 for such coverage) of at least 1 percent. 

12 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF13 FERED.—In the case of a group health plan that offers 

14 a participant or beneficiary two or more benefit package 

15 options under the plan, the requirements of this section 

16 shall be applied separately with respect to each such op17 tion. 

18 ‘‘(e) DEFINITIONS.—For purposes of this section—

19 ‘‘(1) TREATMENT LIMITATION.—The term 

20 ‘treatment limitation’ means, with respect to benefits 

21 under a group health plan or health insurance cov22 erage, any day or visit limits imposed on coverage of 

23 benefits under the plan or coverage during a period 

24 of time. 
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1 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi2 nancial requirement’ means, with respect to benefits 

3 under a group health plan or health insurance cov4 erage, any deductible, coinsurance, or cost-sharing 

5 or an annual or lifetime dollar limit imposed with re6 spect to the benefits under the plan or coverage. 

7 ‘‘(3) MEDICAL OR SURGICAL BENEFITS.—The 

8 term ‘medical or surgical benefits’ means benefits 

9 with respect to medical or surgical services, as de10 fined under the terms of the plan or coverage (as the 

11 case may be), but does not include substance abuse 

12 treatment benefits. 

13 ‘‘(4) SUBSTANCE ABUSE TREATMENT BENE14 FITS.—The term ‘substance abuse treatment bene15 fits’ means benefits with respect to substance abuse 

16 treatment services. 

17 ‘‘(5) SUBSTANCE ABUSE TREATMENT SERV18 ICES.—The term ‘substance abuse services’ means 

19 any of the following items and services provided for 

20 the treatment of substance abuse: 

21 ‘‘(A) Inpatient treatment, including detoxi22 fication. 

23 ‘‘(B) Non-hospital residential treatment. 

24 ‘‘(C) Outpatient treatment, including 

25 screening and assessment, medication manage-
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1 ment, individual, group, and family counseling, 

2 and relapse prevention. 

3 ‘‘(D) Prevention services, including health 

4 education and individual and group counseling 

5 to encourage the reduction of risk factors for 

6 substance abuse. 

7 ‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 

8 abuse’ includes chemical dependency. 

9 ‘‘(f) NOTICE.—A group health plan under this part 

10 shall comply with the notice requirement under section 

11 714(f) of the Employee Retirement Income Security Act 

12 of 1974 with respect to the requirements of this section 

13 as if such section applied to such plan.’’. 

14 (B) CONFORMING AMENDMENT.—Section 

15 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is 

16 amended by striking ‘‘section 2704’’ and insert17 ing ‘‘sections 2704 and 2707’’. 

18 (2) ERISA AMENDMENTS.—

19 (A) IN GENERAL.—Subpart B of part 7 of 

20 subtitle B of title I of the Employee Retirement 

21 Income Security Act of 1974 is amended by 

22 adding at the end the following new section: 
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1 ‘‘SEC. 714. PARITY IN THE APPLICATION OF TREATMENT 

2 LIMITATIONS AND FINANCIAL REQUIRE3 MENTS TO SUBSTANCE ABUSE TREATMENT 

4 BENEFITS. 

5 ‘‘(a) IN GENERAL.—In the case of a group health 

6 plan (or health insurance coverage offered in connection 

7 with such a plan) that provides both medical and surgical 

8 benefits and substance abuse treatment benefits, the plan 

9 or coverage shall not impose treatment limitations or fi10 nancial requirements on the substance abuse treatment 

11 benefits unless similar limitations or requirements are im12 posed for medical and surgical benefits. 

13 ‘‘(b) CONSTRUCTION.—Nothing in this section shall 

14 be construed—

15 ‘‘(1) as requiring a group health plan (or health 

16 insurance coverage offered in connection with such a 

17 plan) to provide any substance abuse treatment ben18 efits; or 

19 ‘‘(2) to prevent a group health plan or a health 

20 insurance issuer offering group health insurance cov21 erage from negotiating the level and type of reim22 bursement with a provider for care provided in ac23 cordance with this section. 

24 ‘‘(c) EXEMPTIONS.—

25 ‘‘(1) SMALL EMPLOYER EXEMPTION.—
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1 ‘‘(A) IN GENERAL.—This section shall not 

2 apply to any group health plan (and group 

3 health insurance coverage offered in connection 

4 with a group health plan) for any plan year of 

5 a small employer. 

6 ‘‘(B) SMALL EMPLOYER.—For purposes of 

7 subparagraph (A), the term ‘small employer’ 

8 means, in connection with a group health plan 

9 with respect to a calendar year and a plan year, 

10 an employer who employed an average of at 

11 least 2 but not more than 50 employees on 

12 business days during the preceding calendar 

13 year and who employs at least 2 employees on 

14 the first day of the plan year. 

15 ‘‘(C) APPLICATION OF CERTAIN RULES IN

16 DETERMINATION OF EMPLOYER SIZE.—For 

17 purposes of this paragraph—

18 ‘‘(i) APPLICATION OF AGGREGATION

19 RULE FOR EMPLOYERS.—Rules similar to 

20 the rules under subsections (b), (c), (m), 

21 and (o) of section 414 of the Internal Rev22 enue Code of 1986 shall apply for purposes 

23 of treating persons as a single employer. 

24 ‘‘(ii) EMPLOYERS NOT IN EXISTENCE

25 IN PRECEDING YEAR.—In the case of an 
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1 employer which was not in existence 

2 throughout the preceding calendar year, 

3 the determination of whether such em4 ployer is a small employer shall be based 

5 on the average number of employees that 

6 it is reasonably expected such employer 

7 will employ on business days in the current 

8 calendar year. 

9 ‘‘(iii) PREDECESSORS.—Any reference 

10 in this paragraph to an employer shall in11 clude a reference to any predecessor of 

12 such employer. 

13 ‘‘(2) INCREASED COST EXEMPTION.—This sec14 tion shall not apply with respect to a group health 

15 plan (or health insurance coverage offered in connec16 tion with a group health plan) if the application of 

17 this section to such plan (or to such coverage) re18 sults in an increase in the cost under the plan (or 

19 for such coverage) of at least 1 percent. 

20 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF21 FERED.—In the case of a group health plan that offers 

22 a participant or beneficiary two or more benefit package 

23 options under the plan, the requirements of this section 

24 shall be applied separately with respect to each such op25 tion. 
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1 ‘‘(e) DEFINITIONS.—For purposes of this section—

2 ‘‘(1) TREATMENT LIMITATION.—The term 

3 ‘treatment limitation’ means, with respect to benefits 

4 under a group health plan or health insurance cov5 erage, any day or visit limits imposed on coverage of 

6 benefits under the plan or coverage during a period 

7 of time. 

8 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi9 nancial requirement’ means, with respect to benefits 

10 under a group health plan or health insurance cov11 erage, any deductible, coinsurance, or cost-sharing 

12 or an annual or lifetime dollar limit imposed with re13 spect to the benefits under the plan or coverage. 

14 ‘‘(3) MEDICAL OR SURGICAL BENEFITS.—The 

15 term ‘medical or surgical benefits’ means benefits 

16 with respect to medical or surgical services, as de17 fined under the terms of the plan or coverage (as the 

18 case may be), but does not include substance abuse 

19 treatment benefits. 

20 ‘‘(4) SUBSTANCE ABUSE TREATMENT BENE21 FITS.—The term ‘substance abuse treatment bene22 fits’ means benefits with respect to substance abuse 

23 treatment services. 

24 ‘‘(5) SUBSTANCE ABUSE TREATMENT SERV25 ICES.—The term ‘substance abuse services’ means 
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1 any of the following items and services provided for 

2 the treatment of substance abuse: 

3 ‘‘(A) Inpatient treatment, including detoxi4 fication. 

5 ‘‘(B) Non-hospital residential treatment. 

6 ‘‘(C) Outpatient treatment, including 

7 screening and assessment, medication manage8 ment, individual, group, and family counseling, 

9 and relapse prevention. 

10 ‘‘(D) Prevention services, including health 

11 education and individual and group counseling 

12 to encourage the reduction of risk factors for 

13 substance abuse. 

14 ‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 

15 abuse’ includes chemical dependency. 

16 ‘‘(f) NOTICE UNDER GROUP HEALTH PLAN.—The 

17 imposition of the requirements of this section shall be 

18 treated as a material modification in the terms of the plan 

19 described in section 102(a)(1), for purposes of assuring 

20 notice of such requirements under the plan; except that 

21 the summary description required to be provided under the 

22 last sentence of section 104(b)(1) with respect to such 

23 modification shall be provided by not later than 60 days 

24 after the first day of the first plan year in which such 

25 requirements apply.’’. 
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1 (B) Section 731(c) of such Act (29 U.S.C. 

2 1191(c)) is amended by striking ‘‘section 711’’ 

3 and inserting ‘‘sections 711 and 714’’. 

4 (C) Section 732(a) of such Act (29 U.S.C. 

5 1191a(a)) is amended by striking ‘‘section 711’’ 

6 and inserting ‘‘sections 711 and 714’’. 

7 (D) The table of contents in section 1 of 

8 such Act is amended by inserting after the item 

9 relating to section 713 the following new item:

‘‘714. Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits.’’.

10 (3) INTERNAL REVENUE CODE AMEND11 MENTS.—(A) Subchapter B of chapter 100 of the 

12 Internal Revenue Code of 1986 (relating to other re13 quirements) is amended by adding at the end the 

14 following new section: 

15 ‘‘SEC. 9813. PARITY IN THE APPLICATION OF TREATMENT 

16 LIMITATIONS AND FINANCIAL REQUIRE17 MENTS TO SUBSTANCE ABUSE TREATMENT 

18 BENEFITS. 

19 ‘‘(a) IN GENERAL.—In the case of a group health 

20 plan that provides both medical and surgical benefits and 

21 substance abuse treatment benefits, the plan shall not im22 pose treatment limitations or financial requirements on 

23 the substance abuse treatment benefits unless similar limi-
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1 tations or requirements are imposed for medical and sur2 gical benefits. 

3 ‘‘(b) CONSTRUCTION.—Nothing in this section shall 

4 be construed—

5 ‘‘(1) as requiring a group health plan to provide 

6 any substance abuse treatment benefits; or 

7 ‘‘(2) to prevent a group health plan from nego8 tiating the level and type of reimbursement with a 

9 provider for care provided in accordance with this 

10 section. 

11 ‘‘(c) EXEMPTIONS.—

12 ‘‘(1) SMALL EMPLOYER EXEMPTION.—

13 ‘‘(A) IN GENERAL.—This section shall not 

14 apply to any group health plan for any plan 

15 year of a small employer. 

16 ‘‘(B) SMALL EMPLOYER.—For purposes of 

17 subparagraph (A), the term ‘small employer’ 

18 means, in connection with a group health plan 

19 with respect to a calendar year and a plan year, 

20 an employer who employed an average of at 

21 least 2 but not more than 50 employees on 

22 business days during the preceding calendar 

23 year and who employs at least 2 employees on 

24 the first day of the plan year. 
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1 ‘‘(C) APPLICATION OF CERTAIN RULES IN

2 DETERMINATION OF EMPLOYER SIZE.—For 

3 purposes of this paragraph—

4 ‘‘(i) APPLICATION OF AGGREGATION

5 RULE FOR EMPLOYERS.—Rules similar to 

6 the rules under subsections (b), (c), (m), 

7 and (o) of section 414 shall apply for pur8 poses of treating persons as a single em9 ployer. 

10 ‘‘(ii) EMPLOYERS NOT IN EXISTENCE

11 IN PRECEDING YEAR.—In the case of an 

12 employer which was not in existence 

13 throughout the preceding calendar year, 

14 the determination of whether such em15 ployer is a small employer shall be based 

16 on the average number of employees that 

17 it is reasonably expected such employer 

18 will employ on business days in the current 

19 calendar year. 

20 ‘‘(iii) PREDECESSORS.—Any reference 

21 in this paragraph to an employer shall in22 clude a reference to any predecessor of 

23 such employer. 

24 ‘‘(2) INCREASED COST EXEMPTION.—This sec25 tion shall not apply with respect to a group health 
16

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1 plan if the application of this section to such plan 

2 results in an increase in the cost under the plan of 

3 at least 1 percent. 

4 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF5 FERED.—In the case of a group health plan that offers 

6 a participant or beneficiary two or more benefit package 

7 options under the plan, the requirements of this section 

8 shall be applied separately with respect to each such op9 tion. 

10 ‘‘(e) DEFINITIONS.—For purposes of this section—

11 ‘‘(1) TREATMENT LIMITATION.—The term 

12 ‘treatment limitation’ means, with respect to benefits 

13 under a group health plan, any day or visit limits 

14 imposed on coverage of benefits under the plan dur15 ing a period of time. 

16 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi17 nancial requirement’ means, with respect to benefits 

18 under a group health plan, any deductible, coinsur19 ance, or cost-sharing or an annual or lifetime dollar 

20 limit imposed with respect to the benefits under the 

21 plan. 

22 ‘‘(3) MEDICAL OR SURGICAL BENEFITS.—The 

23 term ‘medical or surgical benefits’ means benefits 

24 with respect to medical or surgical services, as de-
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1 fined under the terms of the plan, but does not in2 clude substance abuse treatment benefits. 

3 ‘‘(4) SUBSTANCE ABUSE TREATMENT BENE4 FITS.—The term ‘substance abuse treatment bene5 fits’ means benefits with respect to substance abuse 

6 treatment services. 

7 ‘‘(5) SUBSTANCE ABUSE TREATMENT SERV8 ICES.—The term ‘substance abuse services’ means 

9 any of the following items and services provided for 

10 the treatment of substance abuse: 

11 ‘‘(A) Inpatient treatment, including detoxi12 fication. 

13 ‘‘(B) Non-hospital residential treatment. 

14 ‘‘(C) Outpatient treatment, including 

15 screening and assessment, medication manage16 ment, individual, group, and family counseling, 

17 and relapse prevention. 

18 ‘‘(D) Prevention services, including health 

19 education and individual and group counseling 

20 to encourage the reduction of risk factors for 

21 substance abuse. 

22 ‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 

23 abuse’ includes chemical dependency.’’. 
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1 (B) Section 4980D(d)(1) of such Code is 

2 amended by inserting ‘‘(other than a failure attrib3 utable to section 9813)’’ after ‘‘on any failure’’. 

4 (C) The table of sections of subchapter B of 

5 chapter 100 of such Code is amended by adding at 

6 the end the following new item:

‘‘9813. Parity in the application of treatment limitations and financial requirements to substance abuse treatment benefits.’’

7 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B 

8 of title XXVII of the Public Health Service Act is amend9 ed by inserting after section 2752 the following new sec10 tion: 

11 ‘‘SEC. 2753. PARITY IN THE APPLICATION OF TREATMENT 

12 LIMITATIONS AND FINANCIAL REQUIRE13 MENTS TO SUBSTANCE ABUSE BENEFITS. 

14 ‘‘(a) IN GENERAL.—The provisions of section 2707 

15 (other than subsections (e)) shall apply to health insur16 ance coverage offered by a health insurance issuer in the 

17 individual market in the same manner as it applies to 

18 health insurance coverage offered by a health insurance 

19 issuer in connection with a group health plan in the small 

20 or large group market. 

21 ‘‘(b) NOTICE.—A health insurance issuer under this 

22 part shall comply with the notice requirement under sec23 tion 714(f) of the Employee Retirement Income Security 

24 Act of 1974 with respect to the requirements referred to 
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1 in subsection (a) as if such section applied to such issuer 

2 and such issuer were a group health plan.’’. 

3 (2) Section 2762(b)(2) of such Act (42 U.S.C. 

4 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 

5 and inserting ‘‘sections 2751 and 2753’’. 

6 (c) EFFECTIVE DATES.—(1) Subject to paragraph 

7 (3), the amendments made by subsection (a) apply with 

8 respect to group health plans for plan years beginning on 

9 or after January 1, 2004. 

10 (2) The amendments made by subsection (b) apply 

11 with respect to health insurance coverage offered, sold, 

12 issued, renewed, in effect, or operated in the individual 

13 market on or after January 1, 2004. 

14 (3) In the case of a group health plan maintained 

15 pursuant to 1 or more collective bargaining agreements 

16 between employee representatives and 1 or more employ17 ers ratified before the date of enactment of this Act, the 

18 amendments made in subsection (a) shall not apply to plan 

19 years beginning before the later of—

20 (A) the date on which the last collective bar21 gaining agreements relating to the plan terminates 

22 (determined without regard to any extension thereof 

23 agreed to after the date of enactment of this Act), 

24 or 

25 (B) January 1, 2004. 
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1 For purposes of subparagraph (A), any plan amendment 

2 made pursuant to a collective bargaining agreement relat3 ing to the plan which amends the plan solely to conform 

4 to any requirement added by subsection (a) shall not be 

5 treated as a termination of such collective bargaining 

6 agreement. 

7 (d) COORDINATED REGULATIONS.—Section 104(1) 

8 of Health Insurance Portability and Accountability Act of 

9 1996 is amended by striking ‘‘this subtitle (and the 

10 amendments made by this subtitle and section 401)’’ and 

11 inserting ‘‘the provisions of part 7 of subtitle B of title 

12 I of the Employee Retirement Income Security Act of 

13 1974, and the provisions of parts A and C of title XXVII 

14 of the Public Health Service Act, and chapter 1000 of the 

15 Internal Revenue Code of 1986’’. 

16 (e) PREEMPTION.—Nothing in the amendments made 

17 by this section shall be construed to preempt any provision 

18 of State law that provides protections to individuals that 

19 are greater than the protections provided under such 

20 amendments.

Æ