Page 477 TITLE 29—LABOR § 1185a

1See References in Text note below.

under health insurance coverage offered in connection with a group health plan), except that

such coinsurance or other cost-sharing for any

portion of a period within a hospital length of

stay required under subsection (a) of this section may not be greater than such coinsurance

or cost-sharing for any preceding portion of such

stay.

(d) Notice under group health plan

The imposition of the requirements of this

section shall be treated as a material modification in the terms of the plan described in section

1022(a)(1) 1 of this title, for purposes of assuring

notice of such requirements under the plan; except that the summary description required to

be provided under the last sentence of section

1024(b)(1) of this title with respect to such modification shall be provided by not later than 60

days after the first day of the first plan year in

which such requirements apply.

(e) Level and type of reimbursements

Nothing in this section shall be construed to

prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided

in accordance with this section.

(f) Preemption; exception for health insurance

coverage in certain States

(1) In general

The requirements of this section shall not

apply with respect to health insurance coverage if there is a State law (as defined in section 1191(d)(1) of this title) for a State that

regulates such coverage that is described in

any of the following subparagraphs:

(A) Such State law requires such coverage

to provide for at least a 48-hour hospital

length of stay following a normal vaginal delivery and at least a 96-hour hospital length

of stay following a cesarean section.

(B) Such State law requires such coverage

to provide for maternity and pediatric care

in accordance with guidelines established by

the American College of Obstetricians and

Gynecologists, the American Academy of

Pediatrics, or other established professional

medical associations.

(C) Such State law requires, in connection

with such coverage for maternity care, that

the hospital length of stay for such care is

left to the decision of (or required to be

made by) the attending provider in consultation with the mother.

(2) Construction

Section 1191(a)(1) of this title shall not be

construed as superseding a State law described

in paragraph (1).

(Pub. L. 93–406, title I, §711, as added Pub. L.

104–204, title VI, §603(a)(5), Sept. 26, 1996, 110

Stat. 2935.)

REFERENCES IN TEXT

Section 1022(a)(1) of this title, referred to in subsec.

(d), was redesignated section 1022(a) of this title by

Pub. L. 105–34, title XV, §1503(b)(1)(B), Aug. 5, 1997, 111

Stat. 1061.

EFFECTIVE DATE

Section applicable with respect to group health plans

for plan years beginning on and after Jan. 1, 1998, see

section 603(c) of Pub. L. 104–204, set out as an Effective

Date of 1996 Amendment note under section 1003 of this

title.

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1191, 1191a of

this title; title 42 sections 300gg–4, 300gg–51.

§ 1185a. Parity in application of certain limits to

mental health benefits

(a) In general

(1) Aggregate lifetime limits

In the case of a group health plan (or health

insurance coverage offered in connection with

such a plan) that provides both medical and

surgical benefits and mental health benefits—

(A) No lifetime limit

If the plan or coverage does not include an

aggregate lifetime limit on substantially all

medical and surgical benefits, the plan or

coverage may not impose any aggregate lifetime limit on mental health benefits.

(B) Lifetime limit

If the plan or coverage includes an aggregate lifetime limit on substantially all medical and surgical benefits (in this paragraph

referred to as the ‘‘applicable lifetime

limit’’), the plan or coverage shall either—

(i) apply the applicable lifetime limit

both to the medical and surgical benefits

to which it otherwise would apply and to

mental health benefits and not distinguish

in the application of such limit between

such medical and surgical benefits and

mental health benefits; or

(ii) not include any aggregate lifetime

limit on mental health benefits that is less

than the applicable lifetime limit.

(C) Rule in case of different limits

In the case of a plan or coverage that is

not described in subparagraph (A) or (B) and

that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the Secretary shall

establish rules under which subparagraph (B)

is applied to such plan or coverage with respect to mental health benefits by substituting for the applicable lifetime limit an average aggregate lifetime limit that is computed taking into account the weighted average of the aggregate lifetime limits applicable to such categories.

(2) Annual limits

In the case of a group health plan (or health

insurance coverage offered in connection with

such a plan) that provides both medical and

surgical benefits and mental health benefits—

(A) No annual limit

If the plan or coverage does not include an

annual limit on substantially all medical

and surgical benefits, the plan or coverage

may not impose any annual limit on mental

health benefits.

(B) Annual limit

If the plan or coverage includes an annual

limit on substantially all medical and sur-
§ 1185a TITLE 29—LABOR Page 478

gical benefits (in this paragraph referred to

as the ‘‘applicable annual limit’’), the plan

or coverage shall either—

(i) apply the applicable annual limit

both to medical and surgical benefits to

which it otherwise would apply and to

mental health benefits and not distinguish

in the application of such limit between

such medical and surgical benefits and

mental health benefits; or

(ii) not include any annual limit on mental health benefits that is less than the applicable annual limit.

(C) Rule in case of different limits

In the case of a plan or coverage that is

not described in subparagraph (A) or (B) and

that includes no or different annual limits

on different categories of medical and surgical benefits, the Secretary shall establish

rules under which subparagraph (B) is applied to such plan or coverage with respect

to mental health benefits by substituting for

the applicable annual limit an average annual limit that is computed taking into account the weighted average of the annual

limits applicable to such categories.

(b) Construction

Nothing in this section shall be construed—

(1) as requiring a group health plan (or

health insurance coverage offered in connection with such a plan) to provide any mental

health benefits; or

(2) in the case of a group health plan (or

health insurance coverage offered in connection with such a plan) that provides mental

health benefits, as affecting the terms and

conditions (including cost sharing, limits on

numbers of visits or days of coverage, and requirements relating to medical necessity) relating to the amount, duration, or scope of

mental health benefits under the plan or coverage, except as specifically provided in subsection (a) of this section (in regard to parity

in the imposition of aggregate lifetime limits

and annual limits for mental health benefits).

(c) Exemptions

(1) Small employer exemption

(A) In general

This section shall not apply to any group

health plan (and group health insurance coverage offered in connection with a group

health plan) for any plan year of a small employer.

(B) Small employer

For purposes of subparagraph (A), the term

‘‘small employer’’ means, in connection with

a group health plan with respect to a calendar year and a plan year, an employer who

employed an average of at least 2 but not

more than 50 employees on business days

during the preceding calendar year and who

employs at least 2 employees on the first

day of the plan year.

(C) Application of certain rules in determination of employer size

For purposes of this paragraph—

(i) Application of aggregation rule for employers

Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414

of title 26 shall apply for purposes of treating persons as a single employer.

(ii) Employers not in existence in preceding year

In the case of an employer which was not

in existence throughout the preceding calendar year, the determination of whether

such employer is a small employer shall be

based on the average number of employees

that it is reasonably expected such employer will employ on business days in the

current calendar year.

(iii) Predecessors

Any reference in this paragraph to an

employer shall include a reference to any

predecessor of such employer.

(2) Increased cost exemption

This section shall not apply with respect to

a group health plan (or health insurance coverage offered in connection with a group

health plan) if the application of this section

to such plan (or to such coverage) results in an

increase in the cost under the plan (or for such

coverage) of at least 1 percent.

(d) Separate application to each option offered

In the case of a group health plan that offers

a participant or beneficiary two or more benefit

package options under the plan, the requirements of this section shall be applied separately

with respect to each such option.

(e) Definitions

For purposes of this section—

(1) Aggregate lifetime limit

The term ‘‘aggregate lifetime limit’’ means,

with respect to benefits under a group health

plan or health insurance coverage, a dollar

limitation on the total amount that may be

paid with respect to such benefits under the

plan or health insurance coverage with respect

to an individual or other coverage unit.

(2) Annual limit

The term ‘‘annual limit’’ means, with respect to benefits under a group health plan or

health insurance coverage, a dollar limitation

on the total amount of benefits that may be

paid with respect to such benefits in a 12-

month period under the plan or health insurance coverage with respect to an individual or

other coverage unit.

(3) Medical or surgical benefits

The term ‘‘medical or surgical benefits’’

means benefits with respect to medical or surgical services, as defined under the terms of

the plan or coverage (as the case may be), but

does not include mental health benefits.

(4) Mental health benefits

The term ‘‘mental health benefits’’ means

benefits with respect to mental health services, as defined under the terms of the plan or

coverage (as the case may be), but does not include benefits with respect to treatment of

substance abuse or chemical dependency.
Page 479 TITLE 29—LABOR § 1191a

(f) Sunset

This section shall not apply to benefits for

services furnished on or after September 30, 2001.

(Pub. L. 93–406, title I, §712, as added Pub. L.

104–204, title VII, §702(a), Sept. 26, 1996, 110 Stat.

2944.)

EFFECTIVE DATE

Section 702(c) of Pub. L. 104–204 provided that: ‘‘The

amendments made by this section [enacting this section] shall apply with respect to group health plans for

plan years beginning on or after January 1, 1998.’’

Subpart C—General Provisions

§ 1191. Preemption; State flexibility; construction

(a) Continued applicability of State law with respect to health insurance issuers

(1) In general

Subject to paragraph (2) and except as provided in subsection (b) of this section, this

part shall not be construed to supersede any

provision of State law which establishes, implements, or continues in effect any standard

or requirement solely relating to health insurance issuers in connection with group health

insurance coverage except to the extent that

such standard or requirement prevents the application of a requirement of this part.

(2) Continued preemption with respect to

group health plans

Nothing in this part shall be construed to affect or modify the provisions of section 1144 of

this title with respect to group health plans.

(b) Special rules in case of portability requirements

(1) In general

Subject to paragraph (2), the provisions of

this part relating to health insurance coverage

offered by a health insurance issuer supersede

any provision of State law which establishes,

implements, or continues in effect a standard

or requirement applicable to imposition of a

preexisting condition exclusion specifically

governed by section 1181 of this title which differs from the standards or requirements specified in such section.

(2) Exceptions

Only in relation to health insurance coverage offered by a health insurance issuer, the

provisions of this part do not supersede any

provision of State law to the extent that such

provision—

(A) substitutes for the reference to ‘‘6-

month period’’ in section 1181(a)(1) of this

title a reference to any shorter period of

time;

(B) substitutes for the reference to ‘‘12

months’’ and ‘‘18 months’’ in section

1181(a)(2) of this title a reference to any

shorter period of time;

(C) substitutes for the references to ‘‘63

days’’ in sections 1181(c)(2)(A) and (d)(4)(A)

of this title a reference to any greater number of days;

(D) substitutes for the reference to ‘‘30-day

period’’ in sections 1181(b)(2) and (d)(1) of

this title a reference to any greater period;

(E) prohibits the imposition of any preexisting condition exclusion in cases not described in section 1181(d) of this title or expands the exceptions described in such section;

(F) requires special enrollment periods in

addition to those required under section

1181(f) of this title; or

(G) reduces the maximum period permitted

in an affiliation period under section

1181(g)(1)(B) of this title.

(c) Rules of construction

Except as provided in section 1185 of this title,

nothing in this part shall be construed as requiring a group health plan or health insurance coverage to provide specific benefits under the

terms of such plan or coverage.

(d) Definitions

For purposes of this section—

(1) State law

The term ‘‘State law’’ includes all laws, decisions, rules, regulations, or other State action having the effect of law, of any State. A

law of the United States applicable only to the

District of Columbia shall be treated as a

State law rather than a law of the United

States.

(2) State

The term ‘‘State’’ includes a State, the

Northern Mariana Islands, any political subdivisions of a State or such Islands, or any

agency or instrumentality of either.

(Pub. L. 93–406, title I, §731, formerly §704, as

added Pub. L. 104–191, title I, §101(a), Aug. 21,

1996, 110 Stat. 1946; renumbered §731 and amended Pub. L. 104–204, title VI, §603(a)(3), (b)(1),

Sept. 26, 1996, 110 Stat. 2935, 2937.)

AMENDMENTS

1996—Subsec. (c). Pub. L. 104–204, §603(b)(1), substituted ‘‘Except as provided in section 1185 of this

title, nothing’’ for ‘‘Nothing’’.

EFFECTIVE DATE OF 1996 AMENDMENT

Amendment by Pub. L. 104–204 applicable with respect to group health plans for plan years beginning on

and after Jan. 1, 1998, see section 603(c) of Pub. L.

104–204, set out as a note under section 1003 of this title.

EFFECTIVE DATE

Section applicable with respect to group health plans

for plan years beginning after June 30, 1997, except as

otherwise provided, see section 101(g) of Pub. L. 104–191,

set out as a note under section 1181 of this title.

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1144, 1185 of this

title.

§ 1191a. Special rules relating to group health

plans

(a) General exception for certain small group

health plans

The requirements of this part (other than section 1185 of this title) shall not apply to any

group health plan (and group health insurance

coverage offered in connection with a group

health plan) for any plan year if, on the first day

of such plan year, such plan has less than 2 participants who are current employees.