II 

109TH CONGRESS 

1ST SESSION S. 803 

To amend the Employee Retirement Income Security Act of 1974, the 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 SENATE OF THE UNITED STATES 

APRIL 14, 2005 

Mr. COLEMAN (for himself and Mrs. CLINTON) introduced the following bill; 

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Employee Retirement Income Security Act 

of 1974, the 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 Act of 2005’’ or the ‘‘HEART 

6 Act’’. 
2 

•S 803 IS

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 

17 (42 U.S.C. 300gg–4 et seq.) is amended by 

18 adding at the end the following 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 
3 

•S 803 IS

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 
4 

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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. 
5 

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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 2 or more benefit package op15 tions under the plan, the requirements of this section shall 

16 be applied separately with respect to each such option. 

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

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

19 ‘treatment limitation’ means, with respect to benefits 

20 under a group health plan or health insurance cov21 erage, any day or visit limits imposed on coverage of 

22 benefits under the plan or coverage during a period 

23 of time. 

24 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi25 nancial requirement’ means, with respect to benefits 
6 

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1 under a group health plan or health insurance cov2 erage, any deductible, coinsurance, or cost-sharing 

3 or an annual or lifetime dollar limit imposed with re4 spect to the benefits under the plan or coverage. 

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

6 term ‘medical or surgical benefits’ means benefits 

7 with respect to medical or surgical services, as de8 fined under the terms of the plan or coverage (as the 

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

10 treatment benefits. 

11 ‘‘(4) SUBSTANCE ABUSE TREATMENT BENE12 FITS.—The term ‘substance abuse treatment bene13 fits’ means benefits with respect to substance abuse 

14 treatment services. 

15 ‘‘(5) SUBSTANCE ABUSE TREATMENT SERV16 ICES.—The term ‘substance abuse treatment serv17 ices’ means any of the following items and services 

18 provided for the treatment of substance abuse: 

19 ‘‘(A) Inpatient treatment, including detoxi20 fication. 

21 ‘‘(B) Nonhospital residential treatment. 

22 ‘‘(C) Outpatient treatment, including 

23 screening and assessment, medication manage24 ment, individual, group, and family counseling, 

25 and relapse prevention. 
7 

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1 ‘‘(D) Prevention services, including health 

2 education and individual and group counseling 

3 to encourage the reduction of risk factors for 

4 substance abuse. 

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

6 abuse’ includes chemical dependency. 

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

8 shall comply with the notice requirement under section 

9 714(f) of the Employee Retirement Income Security Act 

10 of 1974 with respect to the requirements of this section 

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

12 (B) CONFORMING AMENDMENT.—Section 

13 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is 

14 amended by striking ‘‘section 2704’’ and insert15 ing ‘‘sections 2704 and 2707’’. 

16 (2) ERISAAMENDMENTS.— 

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

18 subtitle B of title I of the Employee Retirement 

19 Income Security Act of 1974 (29 U.S.C. 1185 

20 et seq.) is amended by adding at the end the 

21 following new section: 
8 

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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.— 
9 

•S 803 IS

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 
10 

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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 2 or more benefit package op23 tions under the plan, the requirements of this section shall 

24 be applied separately with respect to each such option. 

25 ‘‘(e) DEFINITIONS.—For purposes of this section: 
11 

•S 803 IS

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

2 ‘treatment limitation’ means, with respect to benefits 

3 under a group health plan or health insurance cov4 erage, any day or visit limits imposed on coverage of 

5 benefits under the plan or coverage during a period 

6 of time. 

7 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi8 nancial requirement’ means, with respect to benefits 

9 under a group health plan or health insurance cov10 erage, any deductible, coinsurance, or cost-sharing 

11 or an annual or lifetime dollar limit imposed with re12 spect to the benefits under the plan or coverage. 

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

14 term ‘medical or surgical benefits’ means benefits 

15 with respect to medical or surgical services, as de16 fined under the terms of the plan or coverage (as the 

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

18 treatment benefits. 

19 ‘‘(4) SUBSTANCE ABUSE TREATMENT BENE20 FITS.—The term ‘substance abuse treatment bene21 fits’ means benefits with respect to substance abuse 

22 treatment services. 

23 ‘‘(5) SUBSTANCE ABUSE TREATMENT SERV24 ICES.—The term ‘substance abuse treatment serv-
12 

•S 803 IS

1 ices’ means any of the following items and services 

2 provided for the treatment of substance abuse: 

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

5 ‘‘(B) Nonhospital 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), for purposes of assuring no20 tice of such requirements under the plan; except that the 

21 summary description required to be provided under section 

22 104(b)(1) with respect to such modification shall be pro23 vided by not later than 60 days after the first day of the 

24 first plan year in which such requirements apply.’’. 

25 (B) CONFORMING AMENDMENTS.— 
13 

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1 (i) Section 731(c) of such Act (29 

2 U.S.C. 1191(c)) is amended by striking 

3 ‘‘section 711’’ and inserting ‘‘sections 711 

4 and 714’’. 

5 (ii) Section 732(a) of such Act (29 

6 U.S.C. 1191a(a)) is amended by striking 

7 ‘‘section 711’’ and inserting ‘‘sections 711 

8 and 714’’. 

9 (iii) The table of contents in section 1 

10 of such Act is amended by inserting after 

11 the item relating to section 713 the fol12 lowing new item: 

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

13 (3) INTERNAL REVENUE CODE AMEND14 MENTS.— 

15 (A) IN GENERAL.—Subchapter B of chap16 ter 100 of the Internal Revenue Code of 1986 

17 (relating to other requirements) is amended by 

18 adding at the end the following new section: 

19 ‘‘SEC. 9813. 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 that provides both medical and surgical benefits and 
14 

•S 803 IS

1 substance abuse treatment benefits, the plan shall not im2 pose treatment limitations or financial requirements on 

3 the substance abuse treatment benefits unless similar limi4 tations or requirements are imposed for medical and sur5 gical benefits. 

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

7 be construed— 

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

9 any substance abuse treatment benefits; or 

10 ‘‘(2) to prevent a group health plan from nego11 tiating the level and type of reimbursement with a 

12 provider for care provided in accordance with this 

13 section. 

14 ‘‘(c) EXEMPTIONS.— 

15 ‘‘(1) SMALL EMPLOYER EXEMPTION.— 

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

17 apply to any group health plan for any plan 

18 year of a small employer. 

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

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

21 means, in connection with a group health plan 

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

23 an employer who employed an average of at 

24 least 2 but not more than 50 employees on 

25 business days during the preceding calendar 
15 

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1 year and who employs at least 2 employees on 

2 the first day of the plan year. 

3 ‘‘(C) APPLICATION OF CERTAIN RULES IN

4 DETERMINATION OF EMPLOYER SIZE.—For 

5 purposes of this paragraph— 

6 ‘‘(i) APPLICATION OF AGGREGATION

7 RULE FOR EMPLOYERS.—Rules similar to 

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

9 and (o) of section 414 shall apply for pur10 poses of treating persons as a single em11 ployer. 

12 ‘‘(ii) EMPLOYERS NOT IN EXISTENCE

13 IN PRECEDING YEAR.—In the case of an 

14 employer which was not in existence 

15 throughout the preceding calendar year, 

16 the determination of whether such em17 ployer is a small employer shall be based 

18 on the average number of employees that 

19 it is reasonably expected such employer 

20 will employ on business days in the current 

21 calendar year. 

22 ‘‘(iii) PREDECESSORS.—Any reference 

23 in this paragraph to an employer shall in24 clude a reference to any predecessor of 

25 such employer. 
16 

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1 ‘‘(2) INCREASED COST EXEMPTION.—This sec2 tion shall not apply with respect to a group health 

3 plan if the application of this section to such plan 

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

5 at least 1 percent. 

6 ‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF7 FERED.—In the case of a group health plan that offers 

8 a participant or beneficiary 2 or more benefit package op9 tions under the plan, the requirements of this section shall 

10 be applied separately with respect to each such option. 

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

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

13 ‘treatment limitation’ means, with respect to benefits 

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

15 imposed on coverage of benefits under the plan dur16 ing a period of time. 

17 ‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi18 nancial requirement’ means, with respect to benefits 

19 under a group health plan, any deductible, coinsur20 ance, or cost-sharing or an annual or lifetime dollar 

21 limit imposed with respect to the benefits under the 

22 plan. 

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

24 term ‘medical or surgical benefits’ means benefits 

25 with respect to medical or surgical services, as de-
17 

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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 treatment serv9 ices’ means any of the following items and services 

10 provided for the treatment of substance abuse: 

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

13 ‘‘(B) Nonhospital 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.’’. 

24 (B) CONFORMING AMENDMENTS.— 
18 

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1 (i) Section 4980D(d)(1) of such Code 

2 is amended by striking ‘‘section 9811’’ and 

3 inserting ‘‘sections 9811 and 9813’’. 

4 (ii) The table of sections of sub5 chapter B of chapter 100 of such Code is 

6 amended by adding at the end the fol7 lowing new item: 

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

8 (b) INDIVIDUAL HEALTH INSURANCE.— 

9 (1) AMENDMENT TO THE PUBLIC HEALTH

10 SERVICE ACT.—Part B of title XXVII of the Public 

11 Health Service Act (42 U.S.C. 300gg–41 et seq.) is 

12 amended by inserting after section 2752 the fol13 lowing new section: 

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

15 LIMITATIONS AND FINANCIAL REQUIRE16 MENTS TO SUBSTANCE ABUSE BENEFITS. 

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

18 (other than subsection (e)) shall apply to health insurance 

19 coverage offered by a health insurance issuer in the indi20 vidual market in the same manner as it applies to health 

21 insurance coverage offered by a health insurance issuer 

22 in connection with a group health plan in the small or 

23 large group market. 
19 

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

2 part shall comply with the notice requirement under sec3 tion 714(f) of the Employee Retirement Income Security 

4 Act of 1974 with respect to the requirements referred to 

5 in subsection (a) as if such section applied to such issuer 

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

7 (2) CONFORMING AMENDMENT.—Section 

8 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) 

9 is amended by striking ‘‘section 2751’’ and inserting 

10 ‘‘sections 2751 and 2753’’. 

11 (c) EFFECTIVE DATES.— 

12 (1) GROUP HEALTH PLANS.—Subject to para13 graph (3), the amendments made by subsection (a) 

14 apply with respect to group health plans for plan 

15 years beginning on or after January 1, 2006. 

16 (2) INDIVIDUAL HEALTH INSURANCE.—The 

17 amendments made by subsection (b) apply with re18 spect to health insurance coverage offered, sold, 

19 issued, renewed, in effect, or operated in the indi20 vidual market on or after January 1, 2006. 

21 (3) SPECIAL RULE.—In the case of a group 

22 health plan maintained pursuant to 1 or more collec23 tive bargaining agreements between employee rep24 resentatives and 1 or more employers ratified before 

25 the date of enactment of this Act, the amendments 
20 

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1 made by subsection (a) shall not apply to plan years 

2 beginning before the later of— 

3 (A) the date on which the last collective 

4 bargaining agreements relating to the plan ter5 minates (determined without regard to any ex6 tension thereof agreed to after the date of en7 actment of this Act), or 

8 (B) January 1, 2006. 

9 For purposes of subparagraph (A), any plan amend10 ment made pursuant to a collective bargaining 

11 agreement relating to the plan which amends the 

12 plan solely to conform to any requirement added by 

13 subsection (a) shall not be treated as a termination 

14 of such collective bargaining agreement. 

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

16 of the Health Insurance Portability and Accountability 

17 Act of 1996 is amended by striking ‘‘this subtitle (and 

18 the amendments made by this subtitle and section 401)’’ 

19 and inserting ‘‘the provisions of part 7 of subtitle B of 

20 title I of the Employee Retirement Income Security Act 

21 of 1974, and the provisions of parts A and C of title 

22 XXVII of the Public Health Service Act, and chapter 100 

23 of the Internal Revenue Code of 1986’’. 

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

25 by this section shall be construed to preempt any provision 
21 

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1 of State law that provides protections to individuals that 

2 are greater than the protections provided under such 

3 amendments. 

Æ