I

104TH CONGRESS

1ST SESSION H. R. 1797

To require employer health benefit plans to meet standards relating to the

nondiscriminatory treatment of neurobiological disorders, and for other

purposes.

IN THE HOUSE OF REPRESENTATIVES

JUNE 8, 1995

Ms. DELAURO (for herself, Mr. MCHALE, Mr. WARD, and Mr. GEJDENSON)

introduced the following bill; which was referred to the Committee on

Ways and Means, and in addition to the Committees on Economic and

Educational Opportunities, and Commerce, 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 require employer health benefit plans to meet standards

relating to the nondiscriminatory treatment of

neurobiological disorders, and for other purposes.

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 ‘‘Equitable Health Care

5 for Neurobiological Disorders Act of 1995’’.

6 SEC. 2. FINDINGS.

7 Congress finds that—
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1 (1) there are sufficient neuroscientific data to

2 document that many severe ‘‘mental’’ illnesses are

3 actually physical illnesses known as neurobiological

4 disorders that are characterized by significant

5 neuroanatomical and neurochemical abnormalities;

6 (2) American families should have adequate

7 health insurance protection for the costs of treating

8 neurobiological disorders that is commensurate with

9 the protections provided for other illnesses;

10 (3) currently, many public and private health

11 insurance programs discriminate against persons

12 with neurobiological disorders by providing more re13 strictive coverage for treatments of those illnesses in

14 comparison to coverage provided for treatments of

15 other medical problems;

16 (4) unequal health insurance coverage contrib17 utes to the destructive and unfair stigmatization of

18 persons with neurobiological disorders that are as

19 beyond the control of the individuals as are cancer,

20 diabetes, and other serious physical health problems;

21 (5) about 95 percent of what is known about

22 both normal and abnormal structure and function of

23 the brain has been learned in the last 10 years, but

24 millions of severely mentally ill people have yet to
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1 benefit from these startling research advances in

2 clinical and basic neuroscience; and

3 (6) according to the National Institutes of Men4 tal Health, equitable insurance coverage for severe

5 mental disorders will yield $2.2 billion annually in

6 net savings through decreased use of general medical

7 services and a substantial decrease in social costs.

8 SEC. 3. STANDARDS FOR NONDISCRIMINATORY TREAT9 MENT OF NEUROBIOLOGICAL DISORDERS

10 FOR EMPLOYER HEALTH BENEFIT PLANS.

11 (a) IN GENERAL.—The standards for the nondiscrim12 inatory and equitable treatment by employer health bene13 fit plans of individuals with neurobiological disorders are

14 requirements that such plans (and carriers offering such

15 plans) provide for coverage of services that are essential

16 to the effective treatment of neurobiological disorders in

17 a manner that—

18 (1) is not more restrictive than coverage pro19 vided for other major physical illnesses;

20 (2) provides adequate financial protection to the

21 person requiring the medical treatment for a

22 neurobiological disorder; and

23 (3) is consistent with effective and common

24 methods of controlling health care costs for other

25 major physical illnesses.
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1 (b) PLAN DEEMED TO MEET STANDARDS.—An em2 ployer health benefit plan shall be deemed to meet the

3 standards described in subsection (a) if the plan provides

4 for the following:

5 (1) Stop-loss protection for catastrophic ex6 penses.

7 (2) Coverage of facility-based care.

8 (3) Coverage of outpatient medical management

9 on a par with other medical procedures to encourage

10 the use of cost-effective ambulatory treatment, in11 cluding treatment in non-traditional settings.

12 (4) Coverage of visits for psychological support13 ive, therapeutic, and rehabilitative services, with co14 insurance and fees set to ensure effective cost con15 trol of high demand services.

16 (5) Coverage of prescription drugs essential to

17 the cost effective treatment of neurobiological dis18 orders.

19 (6) Coverage of medically necessary services for

20 comorbidity of other disorders.

21 SEC. 4. ENFORCEMENT THROUGH EXCISE TAX.

22 (a) IN GENERAL.—Chapter 43 of the Internal Reve23 nue Code of 1986 (relating to qualified pension, etc.,

24 plans) is amended by adding at the end thereof the follow25 ing new section:
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1 ‘‘SEC. 4980C. FAILURE TO COMPLY WITH EMPLOYER

2 HEALTH BENEFIT PLAN STANDARDS FOR

3 NONDISCRIMINATORY TREATMENT FOR

4 NEUROBIOLOGICAL DISORDERS.

5 ‘‘(a) IMPOSITION OF TAX.—There is hereby imposed

6 a tax on the failure of a carrier or an employer health

7 benefit plan to comply with the standards relating to the

8 nondiscriminatory treatment of neurobiological disorders

9 under section 3 of the Equitable Health Care for

10 Neurobiological Disorders Act of 1995.

11 ‘‘(b) AMOUNT OF TAX.—

12 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

13 the tax imposed by subsection (a) shall be an

14 amount not to exceed 25 percent of the amounts re15 ceived by the carrier or under the plan for coverage

16 during the period such failure persists.

17 ‘‘(2) LIMITATION IN CASE OF INDIVIDUAL FAIL18 URES.—In the case of a failure that only relates to

19 specified individuals or employers (and not to the

20 plan generally), the amount of the tax imposed by

21 subsection (a) shall not exceed the aggregate of

22 $100 for each day during which such failure persists

23 for each individual to which such failure relates. A

24 rule similar to the rule of section 4980B(b)(3) shall

25 apply for purposes of this section.
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1 ‘‘(c) LIABILITY FOR TAX.—The tax imposed by this

2 section shall be paid by the carrier.

3 ‘‘(d) EXCEPTIONS.—

4 ‘‘(1) CORRECTIONS WITHIN 30 DAYS.—No tax

5 shall be imposed by subsection (a) by reason of any

6 failure if—

7 ‘‘(A) such failure was due to reasonable

8 cause and not to willful neglect, and

9 ‘‘(B) such failure is corrected within the

10 30-day period beginning on earliest date the

11 carrier knew, or exercising reasonable diligence

12 would have known, that such failure existed.

13 ‘‘(2) WAIVER BY SECRETARY.—In the case of a

14 failure which is due to reasonable cause and not to

15 willful neglect, the Secretary may waive part or all

16 of the tax imposed by subsection (a) to the extent

17 that payment of such tax would be excessive relative

18 to the failure involved.

19 ‘‘(e) DEFINITIONS.—For purposes of this section, the

20 terms ‘carrier’ and ‘employer health benefit plan’ have the

21 respective meanings given such terms in section 5 of the

22 Equitable Health Care for Neurobiological Disorders Act

23 of 1995.’’
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1 (b) CLERICAL AMENDMENT.—The table of sections

2 for chapter 43 of such Code is amended by adding at the

3 end thereof the following new item:

‘‘Sec. 4980C. Failure to comply with employer health benefit plan

standards for nondiscriminatory treatment for

neurobiological disorders.’’.

4 (c) EFFECTIVE DATE.—The amendments made by

5 this subsection shall apply to plan years beginning after

6 December 31, 1995.

7 SEC. 5. DEFINITIONS.

8 In this Act, the following definitions shall apply:

9 (1) CARRIER.—The term ‘‘carrier’’ means any

10 entity which provides health insurance or health ben11 efits in a State, and includes a licensed insurance

12 company, a prepaid hospital or medical service plan,

13 a health maintenance organization, the plan sponsor

14 of a multiple employer welfare arrangement or an

15 employee benefit plan (as defined under the Em16 ployee Retirement Income Security Act of 1974), or

17 any other entity providing a plan of health insurance

18 subject to State insurance regulation.

19 (2) EMPLOYER HEALTH BENEFIT PLAN.—The

20 term ‘‘employer health benefit plan’’ means a health

21 benefit plan (including an employee welfare benefit

22 plan, as defined in section 3(1) of the Employee Re23 tirement Income Security Act of 1974) which is of24 fered to employees through an employer and for
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1 which the employer provides for any contribution to

2 such plan or any premium for such plan are de3 ducted by the employer from compensation to the

4 employee.

5 (3) HEALTH BENEFIT PLAN.—The term

6 ‘‘health benefit plan’’ means any hospital or medical

7 expense incurred policy or certificate, hospital or

8 medical service plan contract, or health maintenance

9 subscriber contract, or a multiple employer welfare

10 arrangement or employee benefit plan (as defined

11 under the Employee Retirement Income Security Act

12 of 1974) which provides benefits with respect to

13 health care services, but does not include—

14 (A) coverage only for accident, dental, vi15 sion, disability income, or long-term care insur16 ance, or any combination thereof,

17 (B) medicare supplemental health insur18 ance,

19 (C) coverage issued as a supplement to li20 ability insurance,

21 (D) worker’s compensation or similar in22 surance, or

23 (E) automobile medical-payment insurance,

24 or any combination thereof.

25 (4) NEUROBIOLOGICAL DISORDER.—
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1 (A) IN GENERAL.—An individual with a

2 ‘‘neurobiological disorder’’ is an individual diag3 nosed with one or more of the following condi4 tions:

5 (i) Affective disorders, including bipo6 lar disorder and major depressive disorder.

7 (ii) Anxiety disorders, including obses8 sive-compulsive disorder and panic dis9 order.

10 (iii) Attention deficit disorders.

11 (iv) Autism and other pervasive devel12 opmental disorders.

13 (v) Psychotic disorders, including

14 schizophrenia spectrum disorders.

15 (vi) Tourette’s disorder.

16 (B) PERIODIC REVIEW OF DEFINITION.—

17 (i) IN GENERAL.—Not later than 6

18 months after the date of the enactment of

19 this Act, the Secretary of Health and

20 Human Services shall promulgate regula21 tions directing the National Institute of

22 Mental Health to conduct a biannual re23 view of the definition of neurobiological

24 disorders under subparagraph (A). In con25 ducting such review, the National Institute
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1 of Mental Health shall consult with extra2 mural researchers to review such definition

3 and make recommendations for necessary

4 revisions.

5 (ii) REVIEW BY ADVISORY COUNCIL

6 REQUIRED.—The Secretary may not pro7 mulgate any regulation modifying the defi8 nition of neurobiological disorders under

9 subsection (a) until the recommendations

10 of the National Institute of Mental Health

11 under clause (i) have been reviewed by the

12 National Advisory Mental Health Council.

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