‘‘(A) IN GENERAL.—With respect to 
a group health plan, if the application 
of this section to such plan results in 
an increase for the plan year involved 
of the actual total costs of coverage 
with respect to medical and surgical 
benefits and mental health and sub-
stance-related 
disorder 
benefits 
under the plan (as determined and 
certified under subparagraph (C)) by 
an amount that exceeds the applica-
ble percentage described in subpara-
graph (B) of the actual total plan 
costs, the provisions of this section 
shall not apply to such plan during 
the following plan year, and such ex-
emption shall apply to the plan for 1 
plan year. 
‘‘(B) 
APPLICABLE
PERCENTAGE.— 
With respect to a plan, the applicable 
percentage described in this para-
graph shall be— 
‘‘(i) 2 percent in the case of 
the first plan year to which this 
paragraph applies, and 
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‘‘(ii) 1 percent in the case of 
each subsequent plan year. 
‘‘(C) 
DETERMINATIONS
BY
ACTU-
ARIES.—Determinations 
as 
to 
in-
creases in actual costs under a plan 
for purposes of this subsection shall 
be made by a qualified and licensed 
actuary who is a member in good 
standing of the American Academy of 
Actuaries. Such determinations shall 
be certified by the actuary and be 
made available to the general public. 
‘‘(D) 6-MONTH DETERMINATIONS.—If 
a group health plan seeks an exemp-
tion under this paragraph, deter-
minations under subparagraph (A) 
shall be made after such plan has 
complied with this section for the 
first 6 months of the plan year in-
volved.’’. 
(f) CHANGE IN EXCLUSION FOR SMALLEST EM-
PLOYERS.—Paragraph (1) of section 9812(c) of 
such Code is amended to read as follows: 
‘‘(1) SMALL EMPLOYER EXEMPTION.— 
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100 
‘‘(A) IN
GENERAL.—This section 
shall not apply to any group health 
plan for any plan year of a small em-
ployer. 
‘‘(B) SMALL
EMPLOYER.—For pur-
poses of subparagraph (A), the term 
‘small employer’ means, with respect 
to a calendar year and a plan year, an 
employer who employed an average 
of at least 2 (or 1 in the case of an em-
ployer residing in a State that per-
mits small groups to include a single 
individual) but not more than 50 em-
ployees on business days during the 
preceding calendar year. For pur-
poses of the preceding sentence, all 
persons treated as a single employer 
under subsection (b), (c), (m), or (o) of 
section 414 shall be treated as 1 em-
ployer and rules similar to rules of 
subparagraphs (B) and (C) of section 
4980D(d)(2) shall apply.’’. 
(g) ELIMINATION
OF SUNSET PROVISION.— 
Section 9812 of such Code is amended by 
striking subsection (f). 
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101 
(h) CONFORMING AMENDMENTS
TO HEAD-
ING.— 
(1) IN GENERAL.—The heading of sec-
tion 9812 of such Code is amended to 
read as follows: 
‘‘SEC. 9812. EQUITY IN MENTAL HEALTH AND SUBSTANCE- 
RELATED DISORDER BENEFITS.’’. 
(2) CLERICAL
AMENDMENT.—The table 
of sections for subchapter B of chapter 
100 of such Code is amended by striking 
the item relating to section 9812 and in-
serting the following new item: 
‘‘Sec. 9812. Equity in mental health and substance-related dis-
order benefits.’’. 
(i) EFFECTIVE DATE.— 
(1) IN GENERAL.—Except as otherwise 
provided in this subsection, the amend-
ments made by this section shall apply 
with respect to plan years beginning on 
or after January 1, 2008. 
(2) 
ELIMINATION
OF
SUNSET.—The 
amendment made by subsection (g) shall 
apply to benefits for services furnished 
after December 31, 2007. 
(3) SPECIAL RULE FOR COLLECTIVE BAR-
GAINING
AGREEMENTS.—In the case of a 
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102 
group health plan maintained pursuant 
to one or more collective bargaining 
agreements between employee represent-
atives and one or more employers ratified 
before the date of the enactment of this 
Act, the amendments made by this sec-
tion (other than subsection (g)) shall not 
apply to plan years beginning before the 
later of— 
(A) the date on which the last of 
the collective bargaining agreements 
relating to the plan terminates (deter-
mined without regard to any exten-
sion thereof agreed to after the date 
of the enactment of this Act), or 
(B) January 1, 2010. 
For purposes of subparagraph (A), any 
plan amendment made pursuant to a col-
lective bargaining agreement relating to 
the plan which amends the plan solely to 
conform to any requirement imposed 
under an amendment under this section 
shall not be treated as a termination of 
such collective bargaining agreement. 
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103 
SEC. 5. GOVERNMENT ACCOUNTABILITY OFFICE STUDIES 
AND REPORTS. 
(a) IMPLEMENTATION OF ACT.— 
(1) STUDY.—The Comptroller General 
of the United States shall conduct a study 
that evaluates the effect of the implemen-
tation of the amendments made by this 
Act on— 
(A) the cost of health insurance 
coverage; 
(B) access to health insurance 
coverage (including the availability of 
in-network providers); 
(C) the quality of health care; 
(D) Medicare, Medicaid, and State 
and local mental health and sub-
stance abuse treatment spending; 
(E) the number of individuals 
with private insurance who received 
publicly funded health care for men-
tal health and substance-related dis-
orders; 
(F) spending on public services, 
such as the criminal justice system, 
special education, and income assist-
ance programs; 
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(G) the use of medical manage-
ment of mental health and substance- 
related disorder benefits and medical 
necessity determinations by group 
health plans (and health insurance 
issuers offering health insurance cov-
erage in connection with such plans) 
and timely access by participants and 
beneficiaries to clinically-indicated 
care for mental health and substance- 
use disorders; and 
(H) other matters as determined 
appropriate by the Comptroller Gen-
eral. 
(2) REPORT.—Not later than 2 years 
after the date of enactment of this Act, 
the Comptroller General shall prepare 
and submit to the appropriate commit-
tees of the Congress a report containing 
the results of the study conducted under 
paragraph (1). 
(b) BIANNUAL REPORT ON OBSTACLES IN OB-
TAINING
COVERAGE.—Every two years, the 
Comptroller General shall submit to each 
House of the Congress a report on obstacles 
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105 
that individuals face in obtaining mental 
health and substance-related disorder care 
under their health plans. 
(c) UNIFORM
PATIENT
PLACEMENT
CRI-
TERIA.—Not later than 18 months after the 
date of the enactment of this Act, the Comp-
troller General shall submit to each House of 
the Congress a report on availability of uni-
form patient placement criteria for mental 
health and substance-related disorders that 
could be used by group health plans and 
health insurance issuers to guide determina-
tions of medical necessity and the extent to 
which health plans utilize such critiera. If 
such criteria do not exist, the report shall in-
clude recommendations on a process for de-
veloping such criteria. 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as 
the ‘‘Paul Wellstone Mental Health and Addic-
tion Equity Act of 2007’’. 
(b) TABLE OF CONTENTS.—The table of con-
tents of this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Amendments to the Employee Retirement Income Secu-
rity Act of 1974. 
Sec. 3. Amendments to the Public Health Service Act relating to 
the group market. 
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106 
Sec. 4. Amendments to the Internal Revenue Code of 1986. 
Sec. 5. Government Accountability Office studies and reports. 
SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN-
COME SECURITY ACT OF 1974. 
(a) EXTENSION
OF PARITY
TO TREATMENT 
LIMITS
AND BENEFICIARY FINANCIAL REQUIRE-
MENTS.—Section 712 of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 
1185a) is amended— 
(1) in subsection (a), by adding at the 
end the following new paragraphs: 
‘‘(3) TREATMENT LIMITS.— 
‘‘(A) NO TREATMENT LIMIT.—If the 
plan or coverage does not include a 
treatment limit (as defined in sub-
paragraph (D)) on substantially all 
medical and surgical benefits in any 
category of items or services, the plan 
or coverage may not impose any treat-
ment limit on mental health and sub-
stance-related disorder benefits that 
are classified in the same category of 
items or services. 
‘‘(B) TREATMENT LIMIT.—If the plan 
or coverage includes a treatment limit 
on substantially all medical and sur-
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107 
gical benefits in any category of items 
or services, the plan or coverage may 
not impose such a treatment limit on 
mental health and substance-related 
disorder benefits for items and serv-
ices within such category that are 
more restrictive than the predominant 
treatment limit that is applicable to 
medical and surgical benefits for 
items and services within such cat-
egory. 
‘‘(C) CATEGORIES
OF
ITEMS
AND 
SERVICES
FOR
APPLICATION
OF
TREAT-
MENT
LIMITS
AND
BENEFICIARY
FINAN-
CIAL
REQUIREMENTS.—For purposes of 
this paragraph and paragraph (4), 
there shall be the following four cat-
egories of items and services for bene-
fits, whether medical and surgical 
benefits or mental health and sub-
stance-related disorder benefits, and 
all medical and surgical benefits and 
all mental health and substance re-
lated benefits shall be classified into 
one of the following categories: 
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108 
‘‘(i) INPATIENT, IN-NETWORK.— 
Items and services furnished on 
an inpatient basis and within a 
network of providers established 
or recognized under such plan or 
coverage. 
‘‘(ii) 
INPATIENT, 
OUT-OF-NET-
WORK.—Items 
and 
services 
fur-
nished on an inpatient basis and 
outside any network of providers 
established or recognized under 
such plan or coverage. 
‘‘(iii) 
OUTPATIENT, 
IN-NET-
WORK.—Items 
and 
services 
fur-
nished on an outpatient basis and 
within a network of providers es-
tablished 
or 
recognized 
under 
such plan or coverage. 
‘‘(iv) OUTPATIENT, OUT-OF-NET-
WORK.—Items 
and 
services 
fur-
nished on an outpatient basis and 
outside any network of providers 
established or recognized under 
such plan or coverage. 
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109 
‘‘(D) TREATMENT
LIMIT
DEFINED.— 
For purposes of this paragraph, the 
term ‘treatment limit’ means, with re-
spect to a plan or coverage, limitation 
on the frequency of treatment, number 
of visits or days of coverage, or other 
similar limit on the duration or scope 
of treatment under the plan or cov-
erage. 
‘‘(E) PREDOMINANCE.—For purposes 
of this subsection, a treatment limit or 
financial requirement with respect to 
a category of items and services is 
considered to be predominant if it is 
the most common or frequent of such 
type of limit or requirement with re-
spect to such category of items and 
services. 
‘‘(4) BENEFICIARY
FINANCIAL
REQUIRE-
MENTS.— 
‘‘(A) NO BENEFICIARY FINANCIAL RE-
QUIREMENT.—If the plan or coverage 
does not include a beneficiary finan-
cial requirement (as defined in sub-
paragraph (C)) on substantially all 
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110 
medical and surgical benefits within 
a category of items and services (spec-
ified under paragraph (3)(C)), the 
plan or coverage may not impose such 
a beneficiary financial requirement 
on mental health and substance-re-
lated disorder benefits for items and 
services within such category. 
‘‘(B) BENEFICIARY
FINANCIAL
RE-
QUIREMENT.— 
‘‘(i) 
TREATMENT
OF 
DEDUCTIBLES, OUT-OF-POCKET
LIM-
ITS, 
AND
SIMILAR
FINANCIAL
RE-
QUIREMENTS.—If the plan or cov-
erage includes a deductible, a lim-
itation on out-of-pocket expenses, 
or similar beneficiary financial 
requirement that does not apply 
separately to individual items and 
services on substantially all med-
ical and surgical benefits within a 
category of items and services (as 
specified in paragraph (3)(C)), the 
plan or coverage shall apply such 
requirement (or, if there is more 
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111 
than one such requirement for 
such category of items and serv-
ices, the predominant requirement 
for such category) both to medical 
and surgical benefits within such 
category and to mental health and 
substance-related disorder bene-
fits within such category and 
shall not distinguish in the appli-
cation of such requirement be-
tween such medical and surgical 
benefits and such mental health 
and 
substance-related 
disorder 
benefits. 
‘‘(ii) OTHER FINANCIAL REQUIRE-
MENTS.—If the plan or coverage in-
cludes a beneficiary financial re-
quirement not described in clause 
(i) on substantially all medical 
and surgical benefits within a cat-
egory of items and services, the 
plan or coverage may not impose 
such financial requirement on 
mental health and substance-re-
lated disorder benefits for items 
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112 
and services within such category 
in a way that is more costly to the 
participant or beneficiary than 
the predominant beneficiary fi-
nancial requirement applicable to 
medical and surgical benefits for 
items and services within such 
category. 
‘‘(C) BENEFICIARY
FINANCIAL
RE-
QUIREMENT DEFINED.—For purposes of 
this paragraph, the term ‘beneficiary 
financial requirement’ includes, with 
respect to a plan or coverage, any de-
ductible, 
coinsurance, 
co-payment, 
other cost sharing, and limitation on 
the total amount that may be paid by 
a participant or beneficiary with re-
spect to benefits under the plan or 
coverage, but does not include the ap-
plication of any aggregate lifetime 
limit or annual limit.’’; and 
(2) in subsection (b)— 
(A) by striking ‘‘construed—’’ and 
all that follows through ‘‘(1) as re-
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113 
quiring’’ and inserting ‘‘construed as 
requiring’’; 
(B) by striking ‘‘; or’’ and inserting 
a period; and 
(C) by striking paragraph (2). 
(b) EXPANSION TO SUBSTANCE-RELATED DIS-
ORDER BENEFITS AND REVISION OF DEFINITION.— 
Such section is further amended— 
(1) by striking ‘‘mental health bene-
fits’’ and inserting ‘‘mental health and 
substance-related disorder benefits’’ each 
place it appears; and 
(2) in paragraph (4) of subsection 
(e)— 
(A) by striking ‘‘MENTAL
HEALTH 
BENEFITS’’ 
and 
inserting 
‘‘MENTAL 
HEALTH
AND
SUBSTANCE-RELATED
DIS-
ORDER BENEFITS’’; 
(B) by striking ‘‘benefits with re-
spect to mental health services’’ and 
inserting ‘‘benefits with respect to 
services for mental health conditions 
or substance-related disorders’’; and 
(C) by striking ‘‘, but does not in-
clude benefits with respect to treat-
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114 
ment of substances abuse or chemical 
dependency’’. 
(c) AVAILABILITY
OF
PLAN
INFORMATION 
ABOUT CRITERIA FOR MEDICAL NECESSITY.—Sub-
section (a) of such section, as amended by sub-
section (a)(1), is further amended by adding at 
the end the following new paragraph: 
‘‘(5) AVAILABILITY
OF
PLAN
INFORMA-
TION.—The criteria for medical necessity 
determinations made under the plan with 
respect to mental health and substance- 
related disorder benefits (or the health in-
surance coverage offered in connection 
with the plan with respect to such bene-
fits) shall be made available by the plan 
administrator (or the health insurance 
issuer offering such coverage) to any cur-
rent or potential participant, beneficiary, 
or contracting provider upon request. The 
reason for any denial under the plan (or 
coverage) of reimbursement or payment 
for services with respect to mental health 
and substance-related disorder benefits in 
the case of any participant or beneficiary 
shall, upon request, be made available by 
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115 
the plan administrator (or the health in-
surance issuer offering such coverage) to 
the participant or beneficiary.’’. 
(d) MINIMUM BENEFIT REQUIREMENTS.—Sub-
section (a) of such section is further amended 
by adding at the end the following new para-
graph: 
‘‘(6) MINIMUM SCOPE OF COVERAGE AND 
EQUITY IN OUT-OF-NETWORK BENEFITS.— 
‘‘(A) MINIMUM
SCOPE
OF
MENTAL 
HEALTH
AND
SUBSTANCE-RELATED
DIS-
ORDER
BENEFITS.—In the case of a 
group health plan (or health insur-
ance coverage offered in connection 
with such a plan) that provides any 
mental health and substance-related 
disorder benefits, the plan or coverage 
shall include benefits for any mental 
health condition or substance-related 
disorder for which benefits are pro-
vided under the benefit plan option of-
fered under chapter 89 of title 5, 
United States Code, with the highest 
average enrollment as of the begin-
ning of the most recent year beginning 
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116 
on or before the beginning of the plan 
year involved. 
‘‘(B) EQUITY IN COVERAGE OF OUT- 
OF-NETWORK BENEFITS.— 
‘‘(i) IN GENERAL.—In the case of 
a plan or coverage that provides 
both medical and surgical bene-
fits and mental health and sub-
stance-related disorder benefits, if 
medical and surgical benefits are 
provided 
for 
substantially 
all 
items and services in a category 
specified in clause (ii) furnished 
outside any network of providers 
established or recognized under 
such plan or coverage, the mental 
health and substance-related dis-
order benefits shall also be pro-
vided for items and services in 
such category furnished outside 
any network of providers estab-
lished or recognized under such 
plan or coverage in accordance 
with the requirements of this sec-
tion. 
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117 
‘‘(ii) CATEGORIES OF ITEMS AND 
SERVICES.—For purposes of clause 
(i), there shall be the following 
three categories of items and serv-
ices for benefits, whether medical 
and surgical benefits or mental 
health and substance-related dis-
order benefits, and all medical 
and surgical benefits and all men-
tal health and substance-related 
disorder benefits shall be classi-
fied into one of the following cat-
egories: 
‘‘(I) 
EMERGENCY.—Items 
and 
services, 
whether 
fur-
nished on an inpatient or out-
patient basis, required for the 
treatment of an emergency 
medical condition (including 
an emergency condition relat-
ing to mental health and sub-
stance-related disorders). 
‘‘(II) 
INPATIENT.—Items 
and services not described in 
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118 
subclause (I) furnished on an 
inpatient basis. 
‘‘(III) 
OUTPATIENT.—Items 
and services not described in 
subclause (I) furnished on an 
outpatient basis.’’. 
(e) REVISION
OF INCREASED COST EXEMP-
TION.—Paragraph (2) of subsection (c) of such 
section is amended to read as follows: 
‘‘(2) INCREASED COST EXEMPTION.— 
‘‘(A) IN GENERAL.—With respect to 
a group health plan (or health insur-
ance coverage offered in connection 
with such a plan), if the application 
of this section to such plan (or cov-
erage) results in an increase for the 
plan year involved of the actual total 
costs of coverage with respect to med-
ical and surgical benefits and mental 
health and substance-related disorder 
benefits under the plan (as deter-
mined and certified under subpara-
graph (C)) by an amount that exceeds 
the applicable percentage described 
in subparagraph (B) of the actual 
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119 
total plan costs, the provisions of this 
section shall not apply to such plan 
(or coverage) during the following 
plan year, and such exemption shall 
apply to the plan (or coverage) for 1 
plan year. 
‘‘(B) 
APPLICABLE
PERCENTAGE.— 
With respect to a plan (or coverage), 
the applicable percentage described 
in this paragraph shall be— 
‘‘(i) 2 percent in the case of the 
first plan year which begins after 
the date of the enactment of the 
Paul Wellstone Mental Health and 
Addiction Equity Act of 2007; and 
‘‘(ii) 1 percent in the case of 
each subsequent plan year. 
‘‘(C) 
DETERMINATIONS
BY
ACTU-
ARIES.—Determinations as to increases 
in actual costs under a plan (or cov-
erage) for purposes of this subsection 
shall be made by a qualified actuary 
who is a member in good standing of 
the American Academy of Actuaries. 
Such determinations shall be certified 
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smartinez on PRODPC61 with BILLS
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by the actuary and be made available 
to the general public. 
‘‘(D) 6-MONTH DETERMINATIONS.—If 
a group health plan (or a health in-
surance issuer offering coverage in 
connection with such a plan) seeks an 
exemption under this paragraph, de-
terminations under subparagraph (A) 
shall be made after such plan (or cov-
erage) has complied with this section 
for the first 6 months of the plan year 
involved. 
‘‘(E) NOTIFICATION.—An election to 
modify coverage of mental health and 
substance-related disorder benefits as 
permitted under this paragraph shall 
be treated as a material modification 
in the terms of the plan as described 
in section 102(a)(1) and shall be sub-
ject to the applicable notice require-
ments under section 104(b)(1).’’. 
(f) CHANGE IN EXCLUSION FOR SMALLEST EM-
PLOYERS.—Subsection (c)(1)(B) of such section 
is amended— 
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(1) by inserting ‘‘(or 1 in the case of an 
employer residing in a State that permits 
small groups to include a single indi-
vidual)’’ after ‘‘at least 2’’ the first place it 
appears; and 
(2) by striking ‘‘and who employs at 
least 2 employees on the first day of the 
plan year’’. 
(g) ELIMINATION
OF SUNSET PROVISION.— 
Such section is amended by striking out sub-
section (f). 
(h) 
CLARIFICATION
REGARDING
PREEMP-
TION.—Such section is further amended by in-
serting after subsection (e) the following new 
subsection: 
‘‘(f) 
PREEMPTION, 
RELATION
TO
STATE 
LAWS.— 
‘‘(1) IN GENERAL.—Nothing in this sec-
tion shall be construed to preempt any 
State law that provides greater consumer 
protections, benefits, methods of access to 
benefits, rights or remedies that are great-
er than the protections, benefits, methods 
of access to benefits, rights or remedies 
provided under this section. 
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‘‘(2) ERISA.—Nothing in this section 
shall be construed to affect or modify the 
provisions of section 514 with respect to 
group health plans.’’. 
(i) CONFORMING
AMENDMENTS
TO
HEAD-
ING.— 
(1) IN GENERAL.—The heading of such 
section is amended to read as follows: 
‘‘SEC. 712. Equity in mental health and substance-related dis-
order benefits.’’. 
(2) CLERICAL
AMENDMENT.—The table 
of contents in section 1 of such Act is 
amended by striking the item relating to 
section 712 and inserting the following 
new item: 
‘‘Sec. 712. Equity in mental health and substance-related dis-
order benefits.’’. 
(j) 
EFFECTIVE
DATE.—The 
amendments 
made by this section shall apply with respect 
to plan years beginning on or after January 1, 
2008. 
SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 
ACT RELATING TO THE GROUP MARKET. 
(a) EXTENSION
OF PARITY
TO TREATMENT 
LIMITS
AND BENEFICIARY FINANCIAL REQUIRE-
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123 
MENTS.—Section 2705 of the Public Health 
Service Act (42 U.S.C. 300gg–5) is amended— 
(1) in subsection (a), by adding at the 
end the following new paragraphs: 
‘‘(3) TREATMENT LIMITS.— 
‘‘(A) NO TREATMENT LIMIT.—If the 
plan or coverage does not include a 
treatment limit (as defined in sub-
paragraph (D)) on substantially all 
medical and surgical benefits in any 
category of items or services (specified 
in subparagraph (C)), the plan or cov-
erage may not impose any treatment 
limit on mental health or substance- 
related disorder benefits that are clas-
sified in the same category of items or 
services. 
‘‘(B) TREATMENT LIMIT.—If the plan 
or coverage includes a treatment limit 
on substantially all medical and sur-
gical benefits in any category of items 
or services, the plan or coverage may 
not impose such a treatment limit on 
mental health or substance-related 
disorder benefits for items and serv-
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124 
ices within such category that is more 
restrictive 
than 
the 
predominant 
treatment limit that is applicable to 
medical and surgical benefits for 
items and services within such cat-
egory. 
‘‘(C) CATEGORIES
OF
ITEMS
AND 
SERVICES
FOR
APPLICATION
OF
TREAT-
MENT
LIMITS
AND
BENEFICIARY
FINAN-
CIAL
REQUIREMENTS.—For purposes of 
this paragraph and paragraph (4), 
there shall be the following five cat-
egories of items and services for bene-
fits, whether medical and surgical 
benefits or mental health and sub-
stance-related disorder benefits, and 
all medical and surgical benefits and 
all mental health and substance re-
lated benefits shall be classified into 
one of the following categories: 
‘‘(i) INPATIENT, IN-NETWORK.— 
Items and services not described 
in clause (v) furnished on an in-
patient basis and within a net-
work of providers established or 
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125 
recognized under such plan or 
coverage. 
‘‘(ii) 
INPATIENT, 
OUT-OF-NET-
WORK.—Items and services not de-
scribed in clause (v) furnished on 
an inpatient basis and outside 
any network of providers estab-
lished or recognized under such 
plan or coverage. 
‘‘(iii) 
OUTPATIENT, 
IN-NET-
WORK.—Items and services not de-
scribed in clause (v) furnished on 
an outpatient basis and within a 
network of providers established 
or recognized under such plan or 
coverage. 
‘‘(iv) OUTPATIENT, OUT-OF-NET-
WORK.—Items and services not de-
scribed in clause (v) furnished on 
an outpatient basis and outside 
any network of providers estab-
lished or recognized under such 
plan or coverage. 
‘‘(v) EMERGENCY
CARE.—Items 
and services, whether furnished 
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126 
on an inpatient or outpatient 
basis or within or outside any net-
work of providers, required for the 
treatment of an emergency med-
ical condition (as defined in sec-
tion 1867(e) of the Social Security 
Act, including an emergency con-
dition relating to mental health 
and substance-related disorders). 
‘‘(D) TREATMENT
LIMIT
DEFINED.— 
For purposes of this paragraph, the 
term ‘treatment limit’ means, with re-
spect to a plan or coverage, limitation 
on the frequency of treatment, number 
of visits or days of coverage, or other 
similar limit on the duration or scope 
of treatment under the plan or cov-
erage. 
‘‘(E) PREDOMINANCE.—For purposes 
of this subsection, a treatment limit or 
financial requirement with respect to 
a category of items and services is 
considered to be predominant if it is 
the most common or frequent of such 
type of limit or requirement with re-
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