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 Com-
mittee 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 con-
cerned 
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.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Help Expand Access 
to Recovery and Treatment (HEART) Act of 2003’’.
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) Substance abuse, if left untreated, is a med-
ical emergency and a private and public health cri-
sis. 
(2) Nothing in this Act should be construed as 
prohibiting application of the concept of parity to 
substance abuse treatment provided by faith-based 
treatment providers. 
SEC. 3. PARITY IN SUBSTANCE ABUSE TREATMENT BENE-
FITS. 
(a) GROUP HEALTH PLANS.—
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.—
(A) IN GENERAL.—Subpart 2 of part A of 
title XXVII of the Public Health Service Act is 
amended by adding at the end the following 
new section: 
‘‘SEC. 2707. PARITY IN THE APPLICATION OF TREATMENT 
LIMITATIONS 
AND 
FINANCIAL 
REQUIRE-
MENTS TO SUBSTANCE ABUSE TREATMENT 
BENEFITS. 
‘‘(a) IN GENERAL.—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 substance abuse treatment benefits, the plan
or coverage shall not impose treatment limitations or fi-
nancial requirements on the substance abuse treatment 
benefits unless similar limitations or requirements are im-
posed for medical and surgical benefits. 
‘‘(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 substance abuse treatment ben-
efits; or 
‘‘(2) to prevent a group health plan or a health 
insurance issuer offering group health insurance cov-
erage from negotiating the level and type of reim-
bursement with a provider for care provided in ac-
cordance with this section. 
‘‘(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 the Internal Rev-
enue Code of 1986 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 em-
ployer 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.
ment, individual, group, and family counseling, 
and relapse prevention. 
‘‘(D) Prevention services, including health 
education and individual and group counseling 
to encourage the reduction of risk factors for 
substance abuse. 
‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 
abuse’ includes chemical dependency. 
‘‘(f) NOTICE.—A group health plan under this part 
shall comply with the notice requirement under section 
714(f) of the Employee Retirement Income Security Act 
of 1974 with respect to the requirements of this section 
as if such section applied to such plan.’’. 
(B) CONFORMING
AMENDMENT.—Section 
2723(c) of such Act (42 U.S.C. 300gg–23(c)) is 
amended by striking ‘‘section 2704’’ and insert-
ing ‘‘sections 2704 and 2707’’. 
(2) ERISA AMENDMENTS.—
(A) IN GENERAL.—Subpart B of part 7 of 
subtitle B of title I of the Employee Retirement 
Income Security Act of 1974 is amended by 
adding at the end the following new section:
‘‘SEC. 714. PARITY IN THE APPLICATION OF TREATMENT 
LIMITATIONS 
AND 
FINANCIAL 
REQUIRE-
MENTS TO SUBSTANCE ABUSE TREATMENT 
BENEFITS. 
‘‘(a) IN GENERAL.—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 substance abuse treatment benefits, the plan 
or coverage shall not impose treatment limitations or fi-
nancial requirements on the substance abuse treatment 
benefits unless similar limitations or requirements are im-
posed for medical and surgical benefits. 
‘‘(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 substance abuse treatment ben-
efits; or 
‘‘(2) to prevent a group health plan or a health 
insurance issuer offering group health insurance cov-
erage from negotiating the level and type of reim-
bursement with a provider for care provided in ac-
cordance with this section. 
‘‘(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 the Internal Rev-
enue Code of 1986 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 em-
ployer 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 in-
clude a reference to any predecessor of 
such employer. 
‘‘(2) INCREASED COST EXEMPTION.—This sec-
tion shall not apply with respect to a group health 
plan (or health insurance coverage offered in connec-
tion with a group health plan) if the application of 
this section to such plan (or to such coverage) re-
sults in an increase in the cost under the plan (or 
for such coverage) of at least 1 percent. 
‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF-
FERED.—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 op-
tion.
‘‘(e) DEFINITIONS.—For purposes of this section—
‘‘(1) 
TREATMENT
LIMITATION.—The 
term 
‘treatment limitation’ means, with respect to benefits 
under a group health plan or health insurance cov-
erage, any day or visit limits imposed on coverage of 
benefits under the plan or coverage during a period 
of time. 
‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi-
nancial requirement’ means, with respect to benefits 
under a group health plan or health insurance cov-
erage, any deductible, coinsurance, or cost-sharing 
or an annual or lifetime dollar limit imposed with re-
spect to the benefits under the plan or coverage. 
‘‘(3) MEDICAL OR SURGICAL BENEFITS.—The 
term ‘medical or surgical benefits’ means benefits 
with respect to medical or surgical services, as de-
fined under the terms of the plan or coverage (as the 
case may be), but does not include substance abuse 
treatment benefits. 
‘‘(4) SUBSTANCE
ABUSE
TREATMENT
BENE-
FITS.—The term ‘substance abuse treatment bene-
fits’ means benefits with respect to substance abuse 
treatment services. 
‘‘(5) SUBSTANCE
ABUSE
TREATMENT
SERV-
ICES.—The term ‘substance abuse services’ means
any of the following items and services provided for 
the treatment of substance abuse: 
‘‘(A) Inpatient treatment, including detoxi-
fication. 
‘‘(B) Non-hospital residential treatment. 
‘‘(C) 
Outpatient 
treatment, 
including 
screening and assessment, medication manage-
ment, individual, group, and family counseling, 
and relapse prevention. 
‘‘(D) Prevention services, including health 
education and individual and group counseling 
to encourage the reduction of risk factors for 
substance abuse. 
‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 
abuse’ includes chemical dependency. 
‘‘(f) 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 102(a)(1), 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 104(b)(1) 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.’’.
(B) Section 731(c) of such Act (29 U.S.C. 
1191(c)) is amended by striking ‘‘section 711’’ 
and inserting ‘‘sections 711 and 714’’. 
(C) Section 732(a) of such Act (29 U.S.C. 
1191a(a)) is amended by striking ‘‘section 711’’ 
and inserting ‘‘sections 711 and 714’’. 
(D) The table of contents in section 1 of 
such Act is amended by inserting after the item 
relating to section 713 the following new item:
‘‘714. Parity in the application of treatment limitations and financial require-
ments to substance abuse treatment benefits.’’.
(3) 
INTERNAL
REVENUE
CODE
AMEND-
MENTS.—(A) Subchapter B of chapter 100 of the 
Internal Revenue Code of 1986 (relating to other re-
quirements) is amended by adding at the end the 
following new section: 
‘‘SEC. 9813. PARITY IN THE APPLICATION OF TREATMENT 
LIMITATIONS 
AND 
FINANCIAL 
REQUIRE-
MENTS TO SUBSTANCE ABUSE TREATMENT 
BENEFITS. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan that provides both medical and surgical benefits and 
substance abuse treatment benefits, the plan shall not im-
pose treatment limitations or financial requirements on 
the substance abuse treatment benefits unless similar limi-
tations or requirements are imposed for medical and sur-
gical benefits. 
‘‘(b) CONSTRUCTION.—Nothing in this section shall 
be construed—
‘‘(1) as requiring a group health plan to provide 
any substance abuse treatment benefits; or 
‘‘(2) to prevent a group health plan from nego-
tiating the level and type of reimbursement with a 
provider for care provided in accordance with this 
section. 
‘‘(c) EXEMPTIONS.—
‘‘(1) SMALL EMPLOYER EXEMPTION.—
‘‘(A) IN GENERAL.—This section shall not 
apply to any 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 shall apply for pur-
poses of treating persons as a single em-
ployer. 
‘‘(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 em-
ployer 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 in-
clude a reference to any predecessor of 
such employer. 
‘‘(2) INCREASED COST EXEMPTION.—This sec-
tion shall not apply with respect to a group health
plan if the application of this section to such plan 
results in an increase in the cost under the plan of 
at least 1 percent. 
‘‘(d) SEPARATE APPLICATION TO EACH OPTION OF-
FERED.—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 op-
tion. 
‘‘(e) DEFINITIONS.—For purposes of this section—
‘‘(1) 
TREATMENT
LIMITATION.—The 
term 
‘treatment limitation’ means, with respect to benefits 
under a group health plan, any day or visit limits 
imposed on coverage of benefits under the plan dur-
ing a period of time. 
‘‘(2) FINANCIAL REQUIREMENT.—The term ‘fi-
nancial requirement’ means, with respect to benefits 
under a group health plan, any deductible, coinsur-
ance, or cost-sharing or an annual or lifetime dollar 
limit imposed with respect to the benefits under the 
plan. 
‘‘(3) MEDICAL OR SURGICAL BENEFITS.—The 
term ‘medical or surgical benefits’ means benefits 
with respect to medical or surgical services, as de-
fined under the terms of the plan, but does not in-
clude substance abuse treatment benefits. 
‘‘(4) SUBSTANCE
ABUSE
TREATMENT
BENE-
FITS.—The term ‘substance abuse treatment bene-
fits’ means benefits with respect to substance abuse 
treatment services. 
‘‘(5) SUBSTANCE
ABUSE
TREATMENT
SERV-
ICES.—The term ‘substance abuse services’ means 
any of the following items and services provided for 
the treatment of substance abuse: 
‘‘(A) Inpatient treatment, including detoxi-
fication. 
‘‘(B) Non-hospital residential treatment. 
‘‘(C) 
Outpatient 
treatment, 
including 
screening and assessment, medication manage-
ment, individual, group, and family counseling, 
and relapse prevention. 
‘‘(D) Prevention services, including health 
education and individual and group counseling 
to encourage the reduction of risk factors for 
substance abuse. 
‘‘(6) SUBSTANCE ABUSE.—The term ‘substance 
abuse’ includes chemical dependency.’’.
(B) Section 4980D(d)(1) of such Code is 
amended by inserting ‘‘(other than a failure attrib-
utable to section 9813)’’ after ‘‘on any failure’’. 
(C) The table of sections of subchapter B of 
chapter 100 of such Code is amended by adding at 
the end the following new item:
‘‘9813. Parity in the application of treatment limitations and financial require-
ments to substance abuse treatment benefits.’’
(b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B 
of title XXVII of the Public Health Service Act is amend-
ed by inserting after section 2752 the following new sec-
tion: 
‘‘SEC. 2753. PARITY IN THE APPLICATION OF TREATMENT 
LIMITATIONS 
AND 
FINANCIAL 
REQUIRE-
MENTS TO SUBSTANCE ABUSE BENEFITS. 
‘‘(a) IN GENERAL.—The provisions of section 2707 
(other than subsections (e)) shall apply to health insur-
ance coverage offered by a health insurance issuer in the 
individual market in the same manner as it applies to 
health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small 
or large group market. 
‘‘(b) NOTICE.—A health insurance issuer under this 
part shall comply with the notice requirement under sec-
tion 714(f) of the Employee Retirement Income Security 
Act of 1974 with respect to the requirements referred to
in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.’’. 
(2) Section 2762(b)(2) of such Act (42 U.S.C. 
300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 
and inserting ‘‘sections 2751 and 2753’’. 
(c) EFFECTIVE DATES.—(1) Subject to paragraph 
(3), the amendments made by subsection (a) apply with 
respect to group health plans for plan years beginning on 
or after January 1, 2004. 
(2) The amendments made by subsection (b) apply 
with respect to health insurance coverage offered, sold, 
issued, renewed, in effect, or operated in the individual 
market on or after January 1, 2004. 
(3) In the case of a group health plan maintained 
pursuant to 1 or more collective bargaining agreements 
between employee representatives and 1 or more employ-
ers ratified before the date of enactment of this Act, the 
amendments made in subsection (a) shall not apply to plan 
years beginning before the later of—
(A) the date on which the last collective bar-
gaining agreements relating to the plan terminates 
(determined without regard to any extension thereof 
agreed to after the date of enactment of this Act), 
or 
(B) January 1, 2004.
For purposes of subparagraph (A), any plan amendment 
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform 
to any requirement added by subsection (a) shall not be 
treated as a termination of such collective bargaining 
agreement. 
(d) COORDINATED REGULATIONS.—Section 104(1) 
of Health Insurance Portability and Accountability Act of 
1996 is amended by striking ‘‘this subtitle (and the 
amendments made by this subtitle and section 401)’’ and 
inserting ‘‘the provisions of part 7 of subtitle B of title 
I of the Employee Retirement Income Security Act of 
1974, and the provisions of parts A and C of title XXVII 
of the Public Health Service Act, and chapter 1000 of the 
Internal Revenue Code of 1986’’. 
(e) PREEMPTION.—Nothing in the amendments made 
by this section shall be construed to preempt any provision 
of State law that provides protections to individuals that 
are greater than the protections provided under such 
amendments.
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