I 
110TH CONGRESS 
2D SESSION 
H. R. 5028 
To amend the Employee Retirement Income Security Act of 1974 and the 
Internal Revenue Code of 1986 to require that group health plans provide 
coverage for pervasive developmental disorders such as autism. 
IN THE HOUSE OF REPRESENTATIVES 
JANUARY 16, 2008 
Mr. WEXLER introduced the following bill; which was referred to the Com-
mittee on Education and Labor, and in addition to the Committee on 
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 concerned 
A BILL 
To amend the Employee Retirement Income Security Act 
of 1974 and the Internal Revenue Code of 1986 to 
require that group health plans provide coverage for per-
vasive developmental disorders such as autism. 
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 ‘‘Fairness in Autism 
Treatment Act of 2007’’. 
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SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN-
COME SECURITY ACT OF 1974. 
(a) IN GENERAL.—Subpart B of part 7 of subtitle 
B of title I of the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add-
ing at the end the following new section: 
‘‘SEC. 714. PARITY FOR PERVASIVE DEVELOPMENTAL DIS-
ORDERS. 
‘‘(a) IN GENERAL.—A group health plan (and a 
health insurance issuer providing health insurance cov-
erage offered in connection with such a plan) that provides 
both medical and surgical benefits shall provide coverage 
for pervasive developmental disorders, including coverage 
for therapeutic, respite, and rehabilitative care for partici-
pants or beneficiaries who have not attained 22 years of 
age. 
‘‘(b) IN-NETWORK AND OUT-OF-NETWORK STAND-
ARDS.— 
‘‘(1) IN
GENERAL.—In the case of a group 
health plan (or health insurance coverage offered in 
connection with such a plan) that provides benefits 
for pervasive developmental disorders, and that pro-
vides both in-network benefits for such disorders and 
out-of-network benefits for such disorders, the re-
quirements of this section shall apply separately with 
respect to benefits provided under the plan (or cov-
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erage) on an in-network basis and benefits provided 
under the plan (or coverage) on an out-of-network 
basis. 
‘‘(2) CLARIFICATION.—Nothing in paragraph 
(1) shall be construed as requiring that a group 
health plan (or health insurance coverage offered in 
connection with such a plan) eliminate an out-of-net-
work provider option from such plan (or coverage) 
pursuant to the terms of the plan (or coverage). 
‘‘(c) OTHER REQUIREMENTS.— 
‘‘(1) ANNUAL
OR
LIFETIME
DOLLAR
LIMITA-
TIONS.—A group health plan (or health insurance 
coverage offered in connection with such a plan) 
may not impose any annual or lifetime dollar limita-
tion on benefits for pervasive developmental dis-
orders unless such limitation applies to all medical 
and surgical benefits and benefits for pervasive de-
velopmental disorders under the plan (or coverage). 
‘‘(2) COST SHARING.—A group health plan (or 
health insurance coverage offered in connection with 
such a plan) may not impose a deductible, coinsur-
ance, or other cost-sharing with respect to the cov-
erage of pervasive developmental disorders under the 
plan (or coverage), which is greater than the deduct-
ible, coinsurance, or other cost-sharing, as the case 
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may be, imposed with respect to medical and sur-
gical benefits under the plan (or coverage). 
‘‘(3) ELIGIBILITY TO ENROLL OR RENEW.—A 
group health plan (or a health insurance issuer pro-
viding health insurance coverage offered in connec-
tion with such a plan) may not deny eligibility, or 
continued eligibility, to enroll or to renew coverage 
under the term of the plan (or coverage), solely for 
the purpose of avoiding the requirements of this sec-
tion. 
‘‘(d) 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 the last sentence of section 102(a), for pur-
poses of assuring notice of such requirements under the 
plan; except that the summary description required to be 
provided under the fourth 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. 
‘‘(e) 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 
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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 (or 1 in the case of an employer residing 
in a State that permits small groups to include 
a single individual) but not more than 50 em-
ployees on business days during the preceding 
calendar 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, 
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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 group health insurance coverage offered in 
connection with a group health plan) if the applica-
tion of this section to such plan (or coverage) results 
in an increase in the cost under the plan (or cov-
erage) of at least 1 percent. 
‘‘(f) PERVASIVE DEVELOPMENTAL DISORDER DE-
FINED.—For purposes of this section, the term ‘pervasive 
developmental disorder’ means any developmental dis-
ability (as defined in section 102(8) of the Developmental 
Disabilities Assistance and Bill of Rights Act of 2000 (42 
U.S.C. 15002(8))). 
‘‘(g) PREEMPTION, RELATION TO STATE LAWS.— 
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‘‘(1) IN
GENERAL.—Nothing in this section 
shall be construed to preempt any State law in effect 
with respect to health insurance coverage to the ex-
tent the requirements of such law at least meet the 
requirements of this section. 
‘‘(2) ERISA.—Nothing in this section shall be 
construed to affect or modify the provisions of sec-
tion 514 with respect to group health plans.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 731(c) of such Act (29 U.S.C. 
1191(c)) is amended by striking ‘‘section 711’’ and 
inserting ‘‘sections 711 and 714’’. 
(2) Section 732(a) of such Act (29 U.S.C. 
1191a(a)) is amended by striking ‘‘section 711’’ and 
inserting ‘‘sections 711 and 714’’. 
(c) CLERICAL AMENDMENT.—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: 
‘‘Sec. 714. Parity for pervasive developmental disorders.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2009. 
SEC. 3. AMENDMENTS TO INTERNAL REVENUE CODE OF 
1986. 
(a) IN GENERAL.—Subchapter B of chapter 100 of 
the Internal Revenue Code of 1986 (relating to group 
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health plan requirements) is amended by adding at the 
end the following new section: 
‘‘SEC. 9813. PARITY FOR PERVASIVE DEVELOPMENTAL DIS-
ORDERS. 
‘‘(a) IN GENERAL.—A group health plan that pro-
vides both medical and surgical benefits shall provide cov-
erage for pervasive developmental disorders, including cov-
erage for therapeutic, respite, and rehabilitative care for 
participants or beneficiaries who have not attained 22 
years of age. 
‘‘(b) IN-NETWORK AND OUT-OF-NETWORK STAND-
ARDS.— 
‘‘(1) IN
GENERAL.—In the case of a group 
health plan that provides benefits for pervasive de-
velopmental disorders, and that provides both in-net-
work benefits for such disorders and out-of-network 
benefits for such disorders, the requirements of this 
section shall apply separately with respect to bene-
fits provided under the plan on an in-network basis 
and benefits provided under the plan on an out-of- 
network basis. 
‘‘(2) CLARIFICATION.—Nothing in paragraph 
(1) shall be construed as requiring that a group 
health plan eliminate an out-of-network provider op-
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tion from such plan pursuant to the terms of the 
plan. 
‘‘(c) OTHER REQUIREMENTS.— 
‘‘(1) ANNUAL
OR
LIFETIME
DOLLAR
LIMITA-
TIONS.—A group health plan may not impose any 
annual or lifetime dollar limitation on benefits for 
pervasive developmental disorders unless such limita-
tion applies to all medical and surgical benefits and 
benefits for pervasive developmental disorders pro-
vided under the plan. 
‘‘(2) COST SHARING.—A group health plan may 
not impose a deductible, coinsurance, or other cost- 
sharing with respect to the coverage of pervasive de-
velopmental disorders under the plan, which is 
greater than the deductible, coinsurance, or other 
cost-sharing, as the case may be, imposed with re-
spect to medical and surgical benefits under the 
plan. 
‘‘(3) ELIGIBILITY TO ENROLL OR RENEW.—A 
group health plan may not deny eligibility, or contin-
ued eligibility, to enroll or to renew coverage under 
the term of the plan, solely for the purpose of avoid-
ing the requirements of this section. 
‘‘(d) EXEMPTIONS.— 
‘‘(1) SMALL EMPLOYER EXEMPTION.— 
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‘‘(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, with respect to a calendar year and a 
plan year, an employer who employed an aver-
age of at least 2 (or 1 in the case of an em-
ployer residing in a State that permits small 
groups to include a single individual) but not 
more than 50 employees on business days dur-
ing the preceding calendar year. For purposes 
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 
employer and rules similar to rules of subpara-
graphs (B) and (C) of section 4980D(d)(2) 
shall apply. 
‘‘(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. 
‘‘(e) PERVASIVE DEVELOPMENTAL DISORDER DE-
FINED.—For purposes of this section, the term ‘pervasive 
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developmental disorder’ means any developmental dis-
ability (as defined in section 102(8) of the Developmental 
Disabilities Assistance and Bill of Rights Act of 2000 (42 
U.S.C. 15002(8)).’’. 
(b) CONFORMING AMENDMENTS.—The table of sec-
tions for subchapter B of chapter 100 of such Code is 
amended by adding at the end the following new item: 
‘‘Sec. 9813. Parity for pervasive developmental disorders.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to group health plans 
for plan years beginning on or after January 1, 2009. 
Æ 
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