I 

109TH CONGRESS 

1ST SESSION H. R. 1402 

To provide for equal coverage of mental health benefits with respect to 

health insurance coverage unless comparable limitations are imposed on 

medical and surgical benefits. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 17, 2005 

Mr. KENNEDY of Rhode Island (for himself and Mr. RAMSTAD) introduced the 

following bill; which was referred to the Committee on Education and the 

Workforce, and in addition to the Committee on Energy 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 provide for equal coverage of mental health benefits with 

respect to health insurance coverage unless comparable 

limitations are imposed on medical and surgical 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 ‘‘Paul Wellstone Mental 

5 Health Equitable Treatment Act of 2005’’. 
2 

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1 SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN2 COME SECURITY ACT OF 1974. 

3 (a) IN GENERAL.—Section 712 of the Employee Re4 tirement Income Security Act of 1974 (29 U.S.C. 1185a) 

5 is amended to read as follows: 

6 ‘‘SEC. 712. MENTAL HEALTH PARITY. 

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

8 plan (or health insurance coverage offered in connection 

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

10 benefits and mental health benefits, such plan or coverage 

11 shall not impose any treatment limitations or financial re12 quirements with respect to the coverage of benefits for 

13 mental illnesses unless comparable treatment limitations 

14 or financial requirements are imposed on medical and sur15 gical benefits. 

16 ‘‘(b) CONSTRUCTION.— 

17 ‘‘(1) IN GENERAL.—Nothing in this section 

18 shall be construed as requiring a group health plan 

19 (or health insurance coverage offered in connection 

20 with such a plan) to provide any mental health bene21 fits. 

22 ‘‘(2) MEDICAL MANAGEMENT OF MENTAL

23 HEALTH BENEFITS.—Consistent with subsection (a), 

24 nothing in this section shall be construed to prevent 

25 the medical management of mental health benefits, 

26 including through concurrent and retrospective utili-
3 

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1 zation review and utilization management practices, 

2 preauthorization, and the application of medical ne3 cessity and appropriateness criteria applicable to be4 havioral health and the contracting and use of a net5 work of participating providers. 

6 ‘‘(3) NO REQUIREMENT OF SPECIFIC SERV7 ICES.—Nothing in this section shall be construed as 

8 requiring a group health plan (or health insurance 

9 coverage offered in connection with such a plan) to 

10 provide coverage for specific mental health services, 

11 except to the extent that the failure to cover such 

12 services would result in a disparity between the cov13 erage of mental health and medical and surgical 

14 benefits. 

15 ‘‘(c) SMALL EMPLOYER EXEMPTION.— 

16 ‘‘(1) IN GENERAL.—This section shall not apply 

17 to any group health plan (and group health insur18 ance coverage offered in connection with a group 

19 health plan) for any plan year of any employer who 

20 employed an average of at least 2 but not more than 

21 50 employees on business days during the preceding 

22 calendar year. 

23 ‘‘(2) APPLICATION OF CERTAIN RULES IN DE24 TERMINATION OF EMPLOYER SIZE.—For purposes of 

25 this subsection— 
4 

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1 ‘‘(A) APPLICATION OF AGGREGATION RULE

2 FOR EMPLOYERS.—Rules similar to the rules 

3 under subsections (b), (c), (m), and (o) of sec4 tion 414 of the Internal Revenue Code of 1986 

5 shall apply for purposes of treating persons as 

6 a single employer. 

7 ‘‘(B) EMPLOYERS NOT IN EXISTENCE IN

8 PRECEDING YEAR.—In the case of an employer 

9 which was not in existence throughout the pre10 ceding calendar year, the determination of 

11 whether such employer is a small employer shall 

12 be based on the average number of employees 

13 that it is reasonably expected such employer 

14 will employ on business days in the current cal15 endar year. 

16 ‘‘(C) PREDECESSORS.—Any reference in 

17 this paragraph to an employer shall include a 

18 reference to any predecessor of such employer. 

19 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF20 FERED.—In the case of a group health plan that offers 

21 a participant or beneficiary two or more benefit package 

22 options under the plan, the requirements of this section 

23 shall be applied separately with respect to each such op24 tion. 
5 

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1 ‘‘(e) IN-NETWORK AND OUT-OF-NETWORK RULES.— 

2 In the case of a plan or coverage option that provides in3 network mental health benefits, out-of-network mental 

4 health benefits may be provided using treatment limita5 tions or financial requirements that are not comparable 

6 to the limitations and requirements applied to medical and 

7 surgical benefits if the plan or coverage provides such in8 network mental health benefits in accordance with sub9 section (a) and provides reasonable access to in-network 

10 providers and facilities. 

11 ‘‘(f) DEFINITIONS.—For purposes of this section— 

12 ‘‘(1) FINANCIAL REQUIREMENTS.—The term 

13 ‘financial requirements’ includes deductibles, coin14 surance, co-payments, other cost sharing, and limita15 tions on the total amount that may be paid by a 

16 participant or beneficiary with respect to benefits 

17 under the plan or health insurance coverage and 

18 shall include the application of annual and lifetime 

19 limits. 

20 ‘‘(2) MEDICAL OR SURGICAL BENEFITS.—The 

21 term ‘medical or surgical benefits’ means benefits 

22 with respect to medical or surgical services, as de23 fined under the terms of the plan or coverage (as the 

24 case may be), but does not include mental health 

25 benefits. 
6 

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1 ‘‘(3) MENTAL HEALTH BENEFITS.—The term 

2 ‘mental health benefits’ means benefits with respect 

3 to services, as defined under the terms and condi4 tions of the plan or coverage (as the case may be), 

5 for all categories of mental health conditions listed 

6 in the Diagnostic and Statistical Manual of Mental 

7 Disorders, Fourth Edition (DSM IV–TR), or the 

8 most recent edition if different than the Fourth Edi9 tion, if such services are included as part of an au10 thorized treatment plan that is in accordance with 

11 standard protocols and such services meet the plan 

12 or issuer’s medical necessity criteria. 

13 ‘‘(4) TREATMENT LIMITATIONS.—The term 

14 ‘treatment limitations’ means limitations on the fre15 quency of treatment, number of visits or days of cov16 erage, or other similar limits on the duration or 

17 scope of treatment under the plan or coverage.’’. 

18 (b) CLERICAL AMENDMENT.—The table of contents 

19 in section 1 of such Act is amended by striking the item 

20 relating to section 712 and inserting the following new 

21 item: 

‘‘Sec. 712. Mental health parity.’’. 

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

23 this section shall apply with respect to plan years begin24 ning on or after January 1, 2006. 
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1 SEC. 3. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 

2 RELATING TO THE GROUP MARKET. 

3 (a) IN GENERAL.—Section 2705 of the Public Health 

4 Service Act (42 U.S.C. 300gg–5) is amended to read as 

5 follows: 

6 ‘‘SEC. 2705. MENTAL HEALTH PARITY. 

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

8 plan (or health insurance coverage offered in connection 

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

10 benefits and mental health benefits, such plan or coverage 

11 shall not impose any treatment limitations or financial re12 quirements with respect to the coverage of benefits for 

13 mental illnesses unless comparable treatment limitations 

14 or financial requirements are imposed on medical and sur15 gical benefits. 

16 ‘‘(b) CONSTRUCTION.— 

17 ‘‘(1) IN GENERAL.—Nothing in this section 

18 shall be construed as requiring a group health plan 

19 (or health insurance coverage offered in connection 

20 with such a plan) to provide any mental health bene21 fits. 

22 ‘‘(2) MEDICAL MANAGEMENT OF MENTAL

23 HEALTH BENEFITS.—Consistent with subsection (a), 

24 nothing in this section shall be construed to prevent 

25 the medical management of mental health benefits, 

26 including through concurrent and retrospective utili-
8 

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1 zation review and utilization management practices, 

2 preauthorization, and the application of medical ne3 cessity and appropriateness criteria applicable to be4 havioral health and the contracting and use of a net5 work of participating providers. 

6 ‘‘(3) NO REQUIREMENT OF SPECIFIC SERV7 ICES.—Nothing in this section shall be construed as 

8 requiring a group health plan (or health insurance 

9 coverage offered in connection with such a plan) to 

10 provide coverage for specific mental health services, 

11 except to the extent that the failure to cover such 

12 services would result in a disparity between the cov13 erage of mental health and medical and surgical 

14 benefits. 

15 ‘‘(c) SMALL EMPLOYER EXEMPTION.— 

16 ‘‘(1) IN GENERAL.—This section shall not apply 

17 to any group health plan (and group health insur18 ance coverage offered in connection with a group 

19 health plan) for any plan year of any employer who 

20 employed an average of at least 2 but not more than 

21 50 employees on business days during the preceding 

22 calendar year. 

23 ‘‘(2) APPLICATION OF CERTAIN RULES IN DE24 TERMINATION OF EMPLOYER SIZE.—For purposes of 

25 this subsection— 
9 

•HR 1402 IH 

1 ‘‘(A) APPLICATION OF AGGREGATION RULE

2 FOR EMPLOYERS.—Rules similar to the rules 

3 under subsections (b), (c), (m), and (o) of sec4 tion 414 of the Internal Revenue Code of 1986 

5 shall apply for purposes of treating persons as 

6 a single employer. 

7 ‘‘(B) EMPLOYERS NOT IN EXISTENCE IN

8 PRECEDING YEAR.—In the case of an employer 

9 which was not in existence throughout the pre10 ceding calendar year, the determination of 

11 whether such employer is a small employer shall 

12 be based on the average number of employees 

13 that it is reasonably expected such employer 

14 will employ on business days in the current cal15 endar year. 

16 ‘‘(C) PREDECESSORS.—Any reference in 

17 this paragraph to an employer shall include a 

18 reference to any predecessor of such employer. 

19 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF20 FERED.—In the case of a group health plan that offers 

21 a participant or beneficiary two or more benefit package 

22 options under the plan, the requirements of this section 

23 shall be applied separately with respect to each such op24 tion. 
10 

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1 ‘‘(e) IN-NETWORK AND OUT-OF-NETWORK RULES.— 

2 In the case of a plan or coverage option that provides in3 network mental health benefits, out-of-network mental 

4 health benefits may be provided using treatment limita5 tions or financial requirements that are not comparable 

6 to the limitations and requirements applied to medical and 

7 surgical benefits if the plan or coverage provides such in8 network mental health benefits in accordance with sub9 section (a) and provides reasonable access to in-network 

10 providers and facilities. 

11 ‘‘(f) DEFINITIONS.—For purposes of this section— 

12 ‘‘(1) FINANCIAL REQUIREMENTS.—The term 

13 ‘financial requirements’ includes deductibles, coin14 surance, co-payments, other cost sharing, and limita15 tions on the total amount that may be paid by a 

16 participant, beneficiary or enrollee with respect to 

17 benefits under the plan or health insurance coverage 

18 and shall include the application of annual and life19 time limits. 

20 ‘‘(2) MEDICAL OR SURGICAL BENEFITS.—The 

21 term ‘medical or surgical benefits’ means benefits 

22 with respect to medical or surgical services, as de23 fined under the terms of the plan or coverage (as the 

24 case may be), but does not include mental health 

25 benefits. 
11 

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1 ‘‘(3) MENTAL HEALTH BENEFITS.—The term 

2 ‘mental health benefits’ means benefits with respect 

3 to services, as defined under the terms and condi4 tions of the plan or coverage (as the case may be), 

5 for all categories of mental health conditions listed 

6 in the Diagnostic and Statistical Manual of Mental 

7 Disorders, Fourth Edition (DSM IV–TR), or the 

8 most recent edition if different than the Fourth Edi9 tion, if such services are included as part of an au10 thorized treatment plan that is in accordance with 

11 standard protocols and such services meet the plan 

12 or issuer’s medical necessity criteria. 

13 ‘‘(4) TREATMENT LIMITATIONS.—The term 

14 ‘treatment limitations’ means limitations on the fre15 quency of treatment, number of visits or days of cov16 erage, or other similar limits on the duration or 

17 scope of treatment under the plan or coverage.’’. 

18 (b) EFFECTIVE DATE.—The amendment made by 

19 this section shall apply with respect to plan years begin20 ning on or after January 1, 2006. 

21 SEC. 4. PREEMPTION. 

22 Nothing in the amendments made by this Act shall 

23 be construed to preempt any provision of State law, with 

24 respect to health insurance coverage offered by a health 

25 insurance issuer in connection with a group health plan, 
12 

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1 that provides protections to enrollees that are greater than 

2 the protections provided under such amendments. Nothing 

3 in the amendments made by this Act shall be construed 

4 to affect or modify section 514 of the Employee Retire5 ment Income Security Act of 1974 (29 U.S.C. 1144). 

6 SEC. 5. GOVERNMENT ACCOUNTABILITY OFFICE STUDY. 

7 (a) STUDY.—The Comptroller General shall conduct 

8 a study that evaluates the effect of the implementation 

9 of the amendments made by this Act on the cost of health 

10 insurance coverage, access to health insurance coverage 

11 (including the availability of in-network providers), the 

12 quality of health care, and other issues as determined ap13 propriate by the Comptroller General. Such study also 

14 shall include an estimation of the costs of extending the 

15 provisions of such amendments to treatment of substance 

16 abuse and chemical dependency. 

17 (b) REPORT.—Not later than 2 years after the date 

18 of enactment of this Act, the Comptroller General shall 

19 prepare and submit to the appropriate committees of Con20 gress a report containing the results of the study con21 ducted under subsection (a). 

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