I 
116TH CONGRESS 
2D SESSION 
H. R. 7539 
To strengthen parity in mental health and substance use disorder benefits. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 9, 2020 
Mr. KENNEDY (for himself, Ms. PORTER, Mr. BILIRAKIS, and Mr. UPTON) 
introduced the following bill; which was referred to the Committee on En-
ergy and Commerce, and in addition to the Committees on Ways and 
Means, and Education and Labor, for a period to be subsequently deter-
mined by the Speaker, in each case for consideration of such provisions 
as fall within the jurisdiction of the committee concerned 
A BILL 
To strengthen parity in mental health and substance use 
disorder benefits. 
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 ‘‘Strengthening Behav-
ioral Health Parity Act’’. 
SEC. 2. STRENGTHENING PARITY IN MENTAL HEALTH AND 
SUBSTANCE USE DISORDER BENEFITS. 
(a) PHSA.— 
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(1) IN GENERAL.—Title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg–11 et seq.) is 
amended by adding at the end the following new 
part: 
‘‘PART D—ADDITIONAL COVERAGE PROVISIONS 
‘‘SEC. 2799A–1. PARITY IN MENTAL HEALTH AND SUB-
STANCE USE DISORDER BENEFITS. 
‘‘(a) IN GENERAL.— 
‘‘(1) AGGREGATE
LIFETIME
LIMITS.—In the 
case of a group health plan or a health insurance 
issuer offering group or individual health insurance 
coverage that provides both medical and surgical 
benefits and mental health or substance use disorder 
benefits— 
‘‘(A) NO LIFETIME LIMIT.—If the plan or 
coverage does not include an aggregate lifetime 
limit on substantially all medical and surgical 
benefits, the plan or coverage may not impose 
any aggregate lifetime limit on mental health or 
substance use disorder benefits. 
‘‘(B) LIFETIME LIMIT.—If the plan or cov-
erage includes an aggregate lifetime limit on 
substantially all medical and surgical benefits 
(in this paragraph referred to as the ‘applicable 
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lifetime limit’), the plan or coverage shall ei-
ther— 
‘‘(i) apply the applicable lifetime limit 
both to the medical and surgical benefits to 
which it otherwise would apply and to 
mental health and substance use disorder 
benefits and not distinguish in the applica-
tion of such limit between such medical 
and surgical benefits and mental health 
and substance use disorder benefits; or 
‘‘(ii) not include any aggregate life-
time limit on mental health or substance 
use disorder benefits that is less than the 
applicable lifetime limit. 
‘‘(C) RULE IN CASE OF DIFFERENT LIM-
ITS.—In the case of a plan or coverage that is 
not described in subparagraph (A) or (B) and 
that includes no or different aggregate lifetime 
limits on different categories of medical and 
surgical benefits, the Secretary shall establish 
rules under which subparagraph (B) is applied 
to such plan or coverage with respect to mental 
health and substance use disorder benefits by 
substituting for the applicable lifetime limit an 
average aggregate lifetime limit that is com-
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puted taking into account the weighted average 
of the aggregate lifetime limits applicable to 
such categories. 
‘‘(2) ANNUAL LIMITS.—In the case of a group 
health plan or a health insurance issuer offering 
group or individual health insurance coverage that 
provides both medical and surgical benefits and 
mental health or substance use disorder benefits— 
‘‘(A) NO ANNUAL LIMIT.—If the plan or 
coverage does not include an annual limit on 
substantially all medical and surgical benefits, 
the plan or coverage may not impose any an-
nual limit on mental health or substance use 
disorder benefits. 
‘‘(B) ANNUAL LIMIT.—If the plan or cov-
erage includes an annual limit on substantially 
all medical and surgical benefits (in this para-
graph referred to as the ‘applicable annual 
limit’), the plan or coverage shall either— 
‘‘(i) apply the applicable annual limit 
both to medical and surgical benefits to 
which it otherwise would apply and to 
mental health and substance use disorder 
benefits and not distinguish in the applica-
tion of such limit between such medical 
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and surgical benefits and mental health 
and substance use disorder benefits; or 
‘‘(ii) not include any annual limit on 
mental health or substance use disorder 
benefits that is less than the applicable an-
nual limit. 
‘‘(C) RULE IN CASE OF DIFFERENT LIM-
ITS.—In the case of a plan or coverage that is 
not described in subparagraph (A) or (B) and 
that includes no or different annual limits on 
different categories of medical and surgical ben-
efits, the Secretary shall establish rules under 
which subparagraph (B) is applied to such plan 
or coverage with respect to mental health and 
substance use disorder benefits by substituting 
for the applicable annual limit an average an-
nual limit that is computed taking into account 
the weighted average of the annual limits appli-
cable to such categories. 
‘‘(3) FINANCIAL REQUIREMENTS AND TREAT-
MENT LIMITATIONS.— 
‘‘(A) IN GENERAL.—In the case of a group 
health plan or a health insurance issuer offering 
group or individual health insurance coverage 
that provides both medical and surgical benefits 
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and mental health or substance use disorder 
benefits, such plan or coverage shall ensure 
that— 
‘‘(i) the financial requirements appli-
cable to such mental health or substance 
use disorder benefits are no more restric-
tive than the predominant financial re-
quirements applied to substantially all 
medical and surgical benefits covered by 
the plan (or coverage), and there are no 
separate cost sharing requirements that 
are applicable only with respect to mental 
health or substance use disorder benefits; 
and 
‘‘(ii) the treatment limitations applica-
ble to such mental health or substance use 
disorder benefits are no more restrictive 
than the predominant treatment limita-
tions applied to substantially all medical 
and surgical benefits covered by the plan 
(or coverage) and there are no separate 
treatment limitations that are applicable 
only with respect to mental health or sub-
stance use disorder benefits. 
‘‘(B) DEFINITIONS.—In this paragraph: 
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‘‘(i) FINANCIAL REQUIREMENT.—The 
term 
‘financial 
requirement’ 
includes 
deductibles, copayments, coinsurance, and 
out-of-pocket expenses, but excludes an ag-
gregate lifetime limit and an annual limit 
subject to paragraphs (1) and (2). 
‘‘(ii) PREDOMINANT.—A financial re-
quirement or treatment limit is considered 
to be predominant if it is the most com-
mon or frequent of such type of limit or 
requirement. 
‘‘(iii) TREATMENT LIMITATION.—The 
term ‘treatment limitation’ includes limits 
on the frequency of treatment, number of 
visits, days of coverage, or other similar 
limits on the scope or duration of treat-
ment. 
‘‘(4) AVAILABILITY OF PLAN INFORMATION.— 
The criteria for medical necessity determinations 
made under the plan with respect to mental health 
or substance use disorder benefits (or the health in-
surance coverage offered in connection with the plan 
with respect to such benefits) shall be made avail-
able by the plan administrator (or the health insur-
ance issuer offering such coverage) in accordance 
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Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
of Labor, and the Secretary of the Treasury, in 
consultation with the Inspector General of the 
Department of Health and Human Services, the 
Inspector General of the Department of Labor, 
and the Inspector General of the Department of 
the Treasury, shall issue a compliance program 
guidance document to help improve compliance 
with this section, section 712 of the Employee 
Retirement Income Security Act of 1974, and 
section 9812 of the Internal Revenue Code of 
1986, as applicable. In carrying out this para-
graph, the Secretaries may take into consider-
ation the 2016 publication of the Department 
of Health and Human Services and the Depart-
ment of Labor, entitled ‘Warning Signs - Plan 
or Policy Non-Quantitative Treatment Limita-
tions (NQTLs) that Require Additional Anal-
ysis to Determine Mental Health Parity Com-
pliance’. 
‘‘(B) EXAMPLES
ILLUSTRATING
COMPLI-
ANCE AND NONCOMPLIANCE.— 
‘‘(i) IN
GENERAL.—The compliance 
program 
guidance 
document 
required 
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under this paragraph shall provide illus-
trative, de-identified examples (that do not 
disclose any protected health information 
or individually identifiable information) of 
previous findings of compliance and non-
compliance with this section, section 712 of 
the Employee Retirement Income Security 
Act of 1974, or section 9812 of the Inter-
nal Revenue Code of 1986, as applicable, 
based on investigations of violations of 
such sections, including— 
‘‘(I) examples illustrating re-
quirements for information disclosures 
and nonquantitative treatment limita-
tions; and 
‘‘(II) descriptions of the viola-
tions uncovered during the course of 
such investigations. 
‘‘(ii) NONQUANTITATIVE TREATMENT 
LIMITATIONS.—To the extent that any ex-
ample described in clause (i) involves a 
finding of compliance or noncompliance 
with regard to any requirement for non-
quantitative treatment limitations, the ex-
ample shall provide sufficient detail to fully 
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explain such finding, including a full de-
scription of the criteria involved for ap-
proving medical and surgical benefits and 
the criteria involved for approving mental 
health and substance use disorder benefits. 
‘‘(iii) ACCESS TO ADDITIONAL INFOR-
MATION REGARDING COMPLIANCE.—In de-
veloping and issuing the compliance pro-
gram guidance document required under 
this paragraph, the Secretaries specified in 
subparagraph (A)— 
‘‘(I) shall enter into interagency 
agreements with the Inspector Gen-
eral of the Department of Health and 
Human Services, the Inspector Gen-
eral of the Department of Labor, and 
the Inspector General of the Depart-
ment of the Treasury to share find-
ings of compliance and noncompliance 
with this section, section 712 of the 
Employee Retirement Income Security 
Act of 1974, or section 9812 of the 
Internal Revenue Code of 1986, as 
applicable; and 
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‘‘(II) shall seek to enter into an 
agreement with a State to share infor-
mation on findings of compliance and 
noncompliance with this section, sec-
tion 712 of the Employee Retirement 
Income Security Act of 1974, or sec-
tion 9812 of the Internal Revenue 
Code of 1986, as applicable. 
‘‘(C) RECOMMENDATIONS.—The compli-
ance program guidance document shall include 
recommendations to advance compliance with 
this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 9812 of the Internal Revenue Code of 
1986, as applicable, and encourage the develop-
ment and use of internal controls to monitor 
adherence to applicable statutes, regulations, 
and program requirements. Such internal con-
trols may include illustrative examples of non-
quantitative treatment limitations on mental 
health and substance use disorder benefits, 
which may fail to comply with this section, sec-
tion 712 of the Employee Retirement Income 
Security Act of 1974, or section 9812 of the In-
ternal Revenue Code of 1986, as applicable, in 
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relation to nonquantitative treatment limita-
tions on medical and surgical benefits. 
‘‘(D) UPDATING
THE
COMPLIANCE
PRO-
GRAM GUIDANCE DOCUMENT.—The Secretary, 
the Secretary of Labor, and the Secretary of 
the Treasury, in consultation with the Inspector 
General of the Department of Health and 
Human Services, the Inspector General of the 
Department of Labor, and the Inspector Gen-
eral of the Department of the Treasury, shall 
update the compliance program guidance docu-
ment every 2 years to include illustrative, de- 
identified examples (that do not disclose any 
protected health information or individually 
identifiable information) of previous findings of 
compliance and noncompliance with this sec-
tion, section 712 of the Employee Retirement 
Income Security Act of 1974, or section 9812 
of the Internal Revenue Code of 1986, as appli-
cable. 
‘‘(7) ADDITIONAL GUIDANCE.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the date of enactment of the 
Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
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of Labor, and the Secretary of the Treasury 
shall issue guidance to group health plans and 
health insurance issuers offering group or indi-
vidual health insurance coverage to assist such 
plans and issuers in satisfying the requirements 
of this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 9812 of the Internal Revenue Code of 
1986, as applicable. 
‘‘(B) DISCLOSURE.— 
‘‘(i) GUIDANCE
FOR
PLANS
AND 
ISSUERS.—The guidance issued under this 
paragraph shall include clarifying informa-
tion and illustrative examples of methods 
that group health plans and health insur-
ance issuers offering group or individual 
health insurance coverage may use for dis-
closing information to ensure compliance 
with the requirements under this section, 
section 712 of the Employee Retirement 
Income Security Act of 1974, or section 
9812 of the Internal Revenue Code of 
1986, as applicable (and any regulations 
promulgated pursuant to such sections, as 
applicable). 
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‘‘(ii) DOCUMENTS FOR PARTICIPANTS, 
BENEFICIARIES, CONTRACTING PROVIDERS, 
OR AUTHORIZED REPRESENTATIVES.—The 
guidance issued under this paragraph shall 
include clarifying information and illus-
trative examples of methods that group 
health plans and health insurance issuers 
offering group or individual health insur-
ance coverage may use to provide any par-
ticipant, beneficiary, contracting provider, 
or authorized representative, as applicable, 
with documents containing information 
that the health plans or issuers are re-
quired to disclose to participants, bene-
ficiaries, contracting providers, or author-
ized representatives to ensure compliance 
with this section, section 712 of the Em-
ployee Retirement Income Security Act of 
1974, or section 9812 of the Internal Rev-
enue Code of 1986, as applicable, compli-
ance with any regulation issued pursuant 
to such respective section, or compliance 
with any other applicable law or regula-
tion. Such guidance shall include informa-
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tion that is comparative in nature with re-
spect to— 
‘‘(I) nonquantitative treatment 
limitations for both medical and sur-
gical benefits and mental health and 
substance use disorder benefits; 
‘‘(II) the processes, strategies, 
evidentiary standards, and other fac-
tors used to apply the limitations de-
scribed in subclause (I); and 
‘‘(III) the application of the limi-
tations described in subclause (I) to 
ensure that such limitations are ap-
plied in parity with respect to both 
medical and surgical benefits and 
mental health and substance use dis-
order benefits. 
‘‘(C) NONQUANTITATIVE TREATMENT LIM-
ITATIONS.—The guidance issued under this 
paragraph shall include clarifying information 
and illustrative examples of methods, processes, 
strategies, evidentiary standards, and other fac-
tors that group health plans and health insur-
ance issuers offering group or individual health 
insurance coverage may use regarding the de-
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velopment and application of nonquantitative 
treatment limitations to ensure compliance with 
this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 9812 of the Internal Revenue Code of 
1986, as applicable (and any regulations pro-
mulgated pursuant to such respective section), 
including— 
‘‘(i) examples of methods of deter-
mining appropriate types of nonquantita-
tive treatment limitations with respect to 
both medical and surgical benefits and 
mental health and substance use disorder 
benefits, including nonquantitative treat-
ment limitations pertaining to— 
‘‘(I) medical management stand-
ards based on medical necessity or ap-
propriateness, or whether a treatment 
is experimental or investigative; 
‘‘(II) limitations with respect to 
prescription drug formulary design; 
and 
‘‘(III) use of fail-first or step 
therapy protocols; 
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‘‘(ii) examples of methods of deter-
mining— 
‘‘(I) network admission standards 
(such as credentialing); and 
‘‘(II) factors used in provider re-
imbursement methodologies (such as 
service type, geographic market, de-
mand for services, and provider sup-
ply, practice size, training, experience, 
and licensure) as such factors apply to 
network adequacy; 
‘‘(iii) examples of sources of informa-
tion that may serve as evidentiary stand-
ards for the purposes of making deter-
minations regarding the development and 
application of nonquantitative treatment 
limitations; 
‘‘(iv) examples of specific factors, and 
the evidentiary standards used to evaluate 
such factors, used by such plans or issuers 
in performing a nonquantitative treatment 
limitation analysis; 
‘‘(v) examples of how specific evi-
dentiary standards may be used to deter-
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mine whether treatments are considered 
experimental or investigative; 
‘‘(vi) examples of how specific evi-
dentiary standards may be applied to each 
service category or classification of bene-
fits; 
‘‘(vii) examples of methods of reach-
ing appropriate coverage determinations 
for new mental health or substance use 
disorder treatments, such as evidence- 
based early intervention programs for indi-
viduals with a serious mental illness and 
types of medical management techniques; 
‘‘(viii) examples of methods of reach-
ing appropriate coverage determinations 
for which there is an indirect relationship 
between the covered mental health or sub-
stance use disorder benefit and a tradi-
tional covered medical and surgical benefit, 
such as residential treatment or hos-
pitalizations involving voluntary or involun-
tary commitment; and 
‘‘(ix) additional illustrative examples 
of methods, processes, strategies, evi-
dentiary standards, and other factors for 
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which the Secretary determines that addi-
tional guidance is necessary to improve 
compliance with this section, section 712 of 
the Employee Retirement Income Security 
Act of 1974, or section 9812 of the Inter-
nal Revenue Code of 1986, as applicable. 
‘‘(D) PUBLIC COMMENT.—Prior to issuing 
any final guidance under this paragraph, the 
Secretary shall provide a public comment period 
of not less than 60 days during which any 
member of the public may provide comments on 
a draft of the guidance. 
‘‘(8) COMPLIANCE REQUIREMENTS.— 
‘‘(A) NONQUANTITATIVE TREATMENT LIM-
ITATION
(NQTL)
REQUIREMENTS.—Beginning 
45 days after the date of enactment of this 
paragraph, in the case of a group health plan 
or a health insurance issuer offering group or 
individual health insurance coverage that pro-
vides both medical and surgical benefits and 
mental health or substance use disorder benefits 
and that imposes nonquantitative treatment 
limitations (referred to in this section as 
‘NQTL’) on mental health or substance use dis-
order benefits, the plan or issuer offering health 
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‘‘(iv) The comparative analyses dem-
onstrating that the processes, strategies, 
evidentiary standards, and other factors 
used to design the NQTL, as written, and 
the operation processes and strategies as 
written and in operation that are used to 
apply the NQTL for mental health or sub-
stance use disorder benefits are com-
parable to, and are applied no more strin-
gently than, the processes, strategies, evi-
dentiary standards, and other factors used 
to design the NQTL, as written, and the 
operation processes and strategies as writ-
ten and in operation that are used to apply 
the NQTL to medical or surgical benefits. 
‘‘(v) A disclosure of the specific find-
ings and conclusions reached by the plan 
or coverage that the results of the analyses 
described in this subparagraph indicate 
that the plan or coverage is in compliance 
with this section. 
‘‘(B) SECRETARY REQUEST PROCESS.— 
‘‘(i) SUBMISSION
UPON
REQUEST.— 
The Secretary shall request that a group 
health plan or a health insurance issuer of-
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fering group or individual health insurance 
coverage submit the comparative analyses 
described in subparagraph (A) for plans 
that involve potential violations of this sec-
tion or complaints regarding noncompli-
ance with this section that concern NQTLs 
and any other instances in which the Sec-
retary determines appropriate. The Sec-
retary shall request not fewer than 20 such 
analyses per year. 
‘‘(ii) ADDITIONAL INFORMATION.—In 
instances in which the Secretary has con-
cluded that the plan or coverage has not 
submitted sufficient information for the 
Secretary to review the comparative anal-
yses described in subparagraph (A), as re-
quested under clause (i), the Secretary 
shall specify to the plan or coverage the in-
formation the plan or coverage must sub-
mit to be responsive to the request under 
clause (i) for the Secretary to review the 
comparative analyses described in subpara-
graph (A) for compliance with this section. 
Nothing in this paragraph shall require the 
Secretary to conclude that a plan is in 
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compliance with this section solely based 
upon the inspection of the comparative 
analyses described in subparagraph (A), as 
requested under clause (i). 
‘‘(iii) REQUIRED ACTION.— 
‘‘(I) IN GENERAL.—In instances 
in which the Secretary has reviewed 
the comparative analyses described in 
subparagraph (A), as requested under 
clause (i), and determined that the 
plan or coverage is not in compliance 
with this section, the plan or cov-
erage— 
‘‘(aa) shall specify to the 
Secretary the actions the plan or 
coverage will take to be in com-
pliance with this section and pro-
vide to the Secretary comparative 
analyses described in subpara-
graph (A) that demonstrate com-
pliance with this section not later 
than 45 days after the initial de-
termination by the Secretary that 
the plan or coverage is not in 
compliance; and 
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‘‘(bb) following the 45-day 
corrective action period under 
item (aa), if the Secretary deter-
mines that the plan or coverage 
still is not in compliance with 
this section, not later than 7 
days after such determination, 
shall notify all individuals en-
rolled in the plan or coverage 
that the plan or coverage has 
been determined to be not in 
compliance with this section. 
‘‘(II) EXEMPTION FROM DISCLO-
SURE.—Documents 
or 
communica-
tions produced in connection with the 
Secretary’s recommendations to the 
plan or coverage shall not be subject 
to disclosure pursuant to section 552 
of title 5, United States Code. 
‘‘(iv) REPORT.—Not later than 1 year 
after the date of enactment of this para-
graph, and not later than October 1 of 
each year thereafter, the Secretary shall 
submit to Congress, and make publicly 
available, a report that contains— 
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‘‘(I) a summary of the compara-
tive analyses requested under clause 
(i), including the identity of each plan 
or coverage that is determined to be 
not in compliance after the final de-
termination by the Secretary de-
scribed in clause (iii)(I)(bb); 
‘‘(II) the Secretary’s conclusions 
as to whether each plan or coverage 
submitted sufficient information for 
the Secretary to review the compara-
tive analyses requested under clause 
(i) for compliance with this section; 
‘‘(III) for each plan or coverage 
that did submit sufficient information 
for the Secretary to review the com-
parative analyses requested under 
clause (i), the Secretary’s conclusions 
as to whether and why the plan or 
coverage is in compliance with the re-
quirements under this section; 
‘‘(IV) the Secretary’s specifica-
tions described in clause (ii) for each 
plan or coverage that the Secretary 
determined did not submit sufficient 
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information for the Secretary to re-
view the comparative analyses re-
quested under clause (i) for compli-
ance with this section; and 
‘‘(V) the Secretary’s specifica-
tions described in clause (iii) of the 
actions each plan or coverage that the 
Secretary determined is not in compli-
ance with this section must take to be 
in compliance with this section, in-
cluding the reason why the Secretary 
determined the plan or coverage is not 
in compliance. 
‘‘(C) COMPLIANCE
PROGRAM
GUIDANCE 
DOCUMENT UPDATE PROCESS.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall include instances of noncompliance 
that the Secretary discovers upon review-
ing the comparative analyses requested 
under subparagraph (B)(i) in the compli-
ance program guidance document de-
scribed in paragraph (6), as it is updated 
every 2 years, except that such instances 
shall not disclose any protected health in-
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formation or individually identifiable infor-
mation. 
‘‘(ii) GUIDANCE AND REGULATIONS.— 
Not later than 18 months after the date of 
enactment of this paragraph, the Secretary 
shall finalize any draft or interim guidance 
and regulations relating to mental health 
parity under this section. Such draft guid-
ance shall include guidance to clarify the 
process and timeline for current and poten-
tial participants and beneficiaries (and au-
thorized representatives and health care 
providers of such participants and bene-
ficiaries) with respect to plans to file com-
plaints of such plans or issuers being in 
violation of this section, including guid-
ance, by plan type, on the relevant State, 
regional, or national office with which such 
complaints should be filed. 
‘‘(iii) STATE.—The Secretary shall 
share information on findings of compli-
ance and noncompliance discovered upon 
reviewing the comparative analyses re-
quested under subparagraph (B)(i) with 
the State where the group health plan is 
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located or the State where the health in-
surance issuer is licensed to do business 
for coverage offered by a health insurance 
issuer in the group market, in accordance 
with paragraph (6)(B)(iii)(II). 
‘‘(b) CONSTRUCTION.—Nothing in this section shall 
be construed— 
‘‘(1) as requiring a group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage to provide any mental 
health or substance use disorder benefits; or 
‘‘(2) in the case of a group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage that provides mental 
health or substance use disorder benefits, as affect-
ing the terms and conditions of the plan or coverage 
relating to such benefits under the plan or coverage, 
except as provided in subsection (a). 
‘‘(c) EXEMPTIONS.— 
‘‘(1) SMALL EMPLOYER EXEMPTION.—This sec-
tion shall not apply to any group health plan and a 
health insurance issuer offering group or individual 
health insurance coverage for any plan year of a 
small employer (as defined in section 2791(e)(4), ex-
cept that for purposes of this paragraph such term 
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shall include employers with 1 employee in the case 
of an employer residing in a State that permits 
small groups to include a single individual). 
‘‘(2) COST EXEMPTION.— 
‘‘(A) IN
GENERAL.—With respect to a 
group health plan or a health insurance issuer 
offering group or individual health insurance 
coverage, if the application of this section to 
such plan (or coverage) 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 use disorder benefits under the plan (as 
determined and certified under subparagraph 
(C)) by an amount that exceeds the applicable 
percentage described in subparagraph (B) of 
the actual total plan costs, the provisions of this 
section shall not apply to such plan (or cov-
erage) during the following plan year, and such 
exemption shall apply to the plan (or coverage) 
for 1 plan year. An employer may elect to con-
tinue to apply mental health and substance use 
disorder parity pursuant to this section with re-
spect to the group health plan (or coverage) in-
volved regardless of any increase in total costs. 
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‘‘(B) APPLICABLE PERCENTAGE.—With re-
spect to a plan (or coverage), the applicable 
percentage described in this subparagraph shall 
be— 
‘‘(i) 2 percent in the case of the first 
plan year in which this section is applied; 
and 
‘‘(ii) 1 percent in the case of each 
subsequent plan year. 
‘‘(C) DETERMINATIONS BY ACTUARIES.— 
Determinations as to increases in actual costs 
under a plan (or coverage) for purposes of this 
section shall be made and certified by a quali-
fied and licensed actuary who is a member in 
good standing of the American Academy of Ac-
tuaries. All such determinations shall be in a 
written report prepared by the actuary. The re-
port, and all underlying documentation relied 
upon by the actuary, shall be maintained by the 
group health plan or health insurance issuer for 
a period of 6 years following the notification 
made under subparagraph (E). 
‘‘(D) 6-MONTH
DETERMINATIONS.—If a 
group health plan (or a health insurance issuer 
offering coverage in connection with a group 
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health plan) seeks an exemption under this 
paragraph, determinations under subparagraph 
(A) shall be made after such plan (or coverage) 
has complied with this section for the first 6 
months of the plan year involved. 
‘‘(E) NOTIFICATION.— 
‘‘(i) IN
GENERAL.—A group health 
plan (or a health insurance issuer offering 
coverage in connection with a group health 
plan) that, based upon a certification de-
scribed under subparagraph (C), qualifies 
for an exemption under this paragraph, 
and elects to implement the exemption, 
shall promptly notify the Secretary, the ap-
propriate State agencies, and participants 
and beneficiaries in the plan of such elec-
tion. 
‘‘(ii) REQUIREMENT.—A notification 
to the Secretary under clause (i) shall in-
clude— 
‘‘(I) a description of the number 
of covered lives under the plan (or 
coverage) involved at the time of the 
notification, and as applicable, at the 
time of any prior election of the cost- 
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exemption under this paragraph by 
such plan (or coverage); 
‘‘(II) for both the plan year upon 
which a cost exemption is sought and 
the year prior, a description of the ac-
tual total costs of coverage with re-
spect to medical and surgical benefits 
and mental health and substance use 
disorder benefits under the plan; and 
‘‘(III) for both the plan year 
upon which a cost exemption is sought 
and the year prior, the actual total 
costs of coverage with respect to men-
tal health and substance use disorder 
benefits under the plan. 
‘‘(iii) CONFIDENTIALITY.—A notifica-
tion to the Secretary under clause (i) shall 
be confidential. The Secretary shall make 
available, upon request and on not more 
than an annual basis, an anonymous 
itemization of such notifications, that in-
cludes— 
‘‘(I) a breakdown of States by 
the size and type of employers submit-
ting such notification; and 
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‘‘(II) a summary of the data re-
ceived under clause (ii). 
‘‘(F) AUDITS
BY
APPROPRIATE
AGEN-
CIES.—To determine compliance with this para-
graph, the Secretary may audit the books and 
records of a group health plan or health insur-
ance issuer relating to an exemption, including 
any actuarial reports prepared pursuant to sub-
paragraph (C), during the 6 year period fol-
lowing the notification of such exemption under 
subparagraph (E). A State agency receiving a 
notification under subparagraph (E) may also 
conduct such an audit with respect to an ex-
emption covered by such notification. 
‘‘(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) AGGREGATE LIFETIME LIMIT.—The term 
‘aggregate lifetime limit’ means, with respect to ben-
efits under a group health plan or health insurance 
coverage, a dollar limitation on the total amount 
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that may be paid with respect to such benefits under 
the plan or health insurance coverage with respect to 
an individual or other coverage unit. 
‘‘(2) ANNUAL LIMIT.—The term ‘annual limit’ 
means, with respect to benefits under a group health 
plan or health insurance coverage, a dollar limitation 
on the total amount of benefits that may be paid 
with respect to such benefits in a 12-month period 
under the plan or health insurance coverage with re-
spect to an individual or other coverage unit. 
‘‘(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 mental health or 
substance use disorder benefits. 
‘‘(4) MENTAL HEALTH BENEFITS.—The term 
‘mental health benefits’ means benefits with respect 
to services for mental health conditions, as defined 
under the terms of the plan and in accordance with 
applicable Federal and State law. 
‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 
The term ‘substance use disorder benefits’ means 
benefits with respect to services for substance use 
disorders, as defined under the terms of the plan 
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and in accordance with applicable Federal and State 
law.’’. 
(2) SUNSET.—Section 2726 of the Public 
Health Service Act (42 U.S.C. 300gg–26) is amend-
ed by adding at the end the following new sub-
section: 
‘‘(f) SUNSET.—The provisions of this section shall 
have no force or effect after the date of the enactment 
of the Strengthening Behavioral Health Parity Act.’’. 
(b) ERISA.—Section 712(a) of the Employee Retire-
ment Income Security Act of 1974 (1185a(a)) is amended 
by adding at the end the following new paragraphs: 
‘‘(6) COMPLIANCE PROGRAM GUIDANCE DOCU-
MENT.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the date of enactment of the 
Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
of Health and Human Services, and the Sec-
retary of the Treasury, in consultation with the 
Inspector General of the Department of Health 
and Human Services, the Inspector General of 
the Department of Labor, and the Inspector 
General of the Department of the Treasury, 
shall issue a compliance program guidance doc-
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ument to help improve compliance with this sec-
tion, section 2799A–1 of the Public Health 
Service Act, and section 9812 of the Internal 
Revenue Code of 1986, as applicable. In car-
rying out this paragraph, the Secretaries may 
take into consideration the 2016 publication of 
the Department of Health and Human Services 
and the Department of Labor, entitled ‘Warn-
ing Signs - Plan or Policy Non-Quantitative 
Treatment Limitations (NQTLs) that Require 
Additional 
Analysis 
to 
Determine 
Mental 
Health Parity Compliance’. 
‘‘(B) EXAMPLES
ILLUSTRATING
COMPLI-
ANCE AND NONCOMPLIANCE.— 
‘‘(i) IN
GENERAL.—The compliance 
program 
guidance 
document 
required 
under this paragraph shall provide illus-
trative, de-identified examples (that do not 
disclose any protected health information 
or individually identifiable information) of 
previous findings of compliance and non-
compliance 
with 
this 
section, 
section 
2799A–1 of the Public Health Service Act, 
or section 9812 of the Internal Revenue 
Code of 1986, as applicable, based on in-
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vestigations of violations of such sections, 
including— 
‘‘(I) examples illustrating re-
quirements for information disclosures 
and nonquantitative treatment limita-
tions; and 
‘‘(II) descriptions of the viola-
tions uncovered during the course of 
such investigations. 
‘‘(ii) NONQUANTITATIVE TREATMENT 
LIMITATIONS.—To the extent that any ex-
ample described in clause (i) involves a 
finding of compliance or noncompliance 
with regard to any requirement for non-
quantitative treatment limitations, the ex-
ample shall provide sufficient detail to fully 
explain such finding, including a full de-
scription of the criteria involved for ap-
proving medical and surgical benefits and 
the criteria involved for approving mental 
health and substance use disorder benefits. 
‘‘(iii) ACCESS TO ADDITIONAL INFOR-
MATION REGARDING COMPLIANCE.—In de-
veloping and issuing the compliance pro-
gram guidance document required under 
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this paragraph, the Secretaries specified in 
subparagraph (A)— 
‘‘(I) shall enter into interagency 
agreements with the Inspector Gen-
eral of the Department of Health and 
Human Services, the Inspector Gen-
eral of the Department of Labor, and 
the Inspector General of the Depart-
ment of the Treasury to share find-
ings of compliance and noncompliance 
with this section, section 2799A–1 of 
the Public Health Service Act, or sec-
tion 9812 of the Internal Revenue 
Code of 1986, as applicable; and 
‘‘(II) shall seek to enter into an 
agreement with a State to share infor-
mation on findings of compliance and 
noncompliance with this section, sec-
tion 2799A–1 of the Public Health 
Service Act, or section 9812 of the In-
ternal Revenue Code of 1986, as ap-
plicable. 
‘‘(C) RECOMMENDATIONS.—The compli-
ance program guidance document shall include 
recommendations to advance compliance with 
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this section, section 2799A–1 of the Public 
Health Service Act, or section 9812 of the In-
ternal Revenue Code of 1986, as applicable, and 
encourage the development and use of internal 
controls to monitor adherence to applicable 
statutes, regulations, and program require-
ments. Such internal controls may include illus-
trative examples of nonquantitative treatment 
limitations on mental health and substance use 
disorder benefits, which may fail to comply with 
this section, section 2799A–1 of the Public 
Health Service Act, or section 9812 of the In-
ternal Revenue Code of 1986, as applicable, in 
relation to nonquantitative treatment limita-
tions on medical and surgical benefits. 
‘‘(D) UPDATING
THE
COMPLIANCE
PRO-
GRAM GUIDANCE DOCUMENT.—The Secretary, 
the Secretary of Health and Human Services, 
and the Secretary of the Treasury, in consulta-
tion with the Inspector General of the Depart-
ment of Health and Human Services, the In-
spector General of the Department of Labor, 
and the Inspector General of the Department of 
the Treasury, shall update the compliance pro-
gram guidance document every 2 years to in-
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clude illustrative, de-identified examples (that 
do not disclose any protected health information 
or individually identifiable information) of pre-
vious findings of compliance and noncompliance 
with this section, section 2799A–1 of the Public 
Health Service Act, or section 9812 of the In-
ternal Revenue Code of 1986, as applicable. 
‘‘(7) ADDITIONAL GUIDANCE.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the date of enactment of the 
Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
of Health and Human Services, and the Sec-
retary of the Treasury shall issue guidance to 
group health plans and health insurance issuers 
offering group or individual health insurance 
coverage to assist such plans and issuers in sat-
isfying the requirements of this section, section 
2799A–1 of the Public Health Service Act, or 
section 9812 of the Internal Revenue Code of 
1986, as applicable. 
‘‘(B) DISCLOSURE.— 
‘‘(i) GUIDANCE
FOR
PLANS
AND 
ISSUERS.—The guidance issued under this 
paragraph shall include clarifying informa-
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tion and illustrative examples of methods 
that group health plans and health insur-
ance issuers offering group or individual 
health insurance coverage may use for dis-
closing information to ensure compliance 
with the requirements under this section, 
section 2799A–1 of the Public Health 
Service Act, or section 9812 of the Inter-
nal Revenue Code of 1986, as applicable, 
(and any regulations promulgated pursu-
ant to such sections, as applicable). 
‘‘(ii) DOCUMENTS FOR PARTICIPANTS, 
BENEFICIARIES, CONTRACTING PROVIDERS, 
OR AUTHORIZED REPRESENTATIVES.—The 
guidance issued under this paragraph shall 
include clarifying information and illus-
trative examples of methods that group 
health plans and health insurance issuers 
offering group or individual health insur-
ance coverage may use to provide any par-
ticipant, beneficiary, contracting provider, 
or authorized representative, as applicable, 
with documents containing information 
that the health plans or issuers are re-
quired to disclose to participants, bene-
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ficiaries, contracting providers, or author-
ized representatives to ensure compliance 
with this section, section 2799A–1 of the 
Public Health Service Act, or section 9812 
of the Internal Revenue Code of 1986, as 
applicable, compliance with any regulation 
issued pursuant to such respective section, 
or compliance with any other applicable 
law or regulation. Such guidance shall in-
clude information that is comparative in 
nature with respect to— 
‘‘(I) nonquantitative treatment 
limitations for both medical and sur-
gical benefits and mental health and 
substance use disorder benefits; 
‘‘(II) the processes, strategies, 
evidentiary standards, and other fac-
tors used to apply the limitations de-
scribed in subclause (I); and 
‘‘(III) the application of the limi-
tations described in subclause (I) to 
ensure that such limitations are ap-
plied in parity with respect to both 
medical and surgical benefits and 
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mental health and substance use dis-
order benefits. 
‘‘(C) NONQUANTITATIVE TREATMENT LIM-
ITATIONS.—The guidance issued under this 
paragraph shall include clarifying information 
and illustrative examples of methods, processes, 
strategies, evidentiary standards, and other fac-
tors that group health plans and health insur-
ance issuers offering group or individual health 
insurance coverage may use regarding the de-
velopment and application of nonquantitative 
treatment limitations to ensure compliance with 
this section, section 2799A–1 of the Public 
Health Service Act, or section 9812 of the In-
ternal Revenue Code of 1986, as applicable 
(and any regulations promulgated pursuant to 
such respective section), including— 
‘‘(i) examples of methods of deter-
mining appropriate types of nonquantita-
tive treatment limitations with respect to 
both medical and surgical benefits and 
mental health and substance use disorder 
benefits, including nonquantitative treat-
ment limitations pertaining to— 
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‘‘(I) medical management stand-
ards based on medical necessity or ap-
propriateness, or whether a treatment 
is experimental or investigative; 
‘‘(II) limitations with respect to 
prescription drug formulary design; 
and 
‘‘(III) use of fail-first or step 
therapy protocols; 
‘‘(ii) examples of methods of deter-
mining— 
‘‘(I) network admission standards 
(such as credentialing); and 
‘‘(II) factors used in provider re-
imbursement methodologies (such as 
service type, geographic market, de-
mand for services, and provider sup-
ply, practice size, training, experience, 
and licensure) as such factors apply to 
network adequacy; 
‘‘(iii) examples of sources of informa-
tion that may serve as evidentiary stand-
ards for the purposes of making deter-
minations regarding the development and 
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application of nonquantitative treatment 
limitations; 
‘‘(iv) examples of specific factors, and 
the evidentiary standards used to evaluate 
such factors, used by such plans or issuers 
in performing a nonquantitative treatment 
limitation analysis; 
‘‘(v) examples of how specific evi-
dentiary standards may be used to deter-
mine whether treatments are considered 
experimental or investigative; 
‘‘(vi) examples of how specific evi-
dentiary standards may be applied to each 
service category or classification of bene-
fits; 
‘‘(vii) examples of methods of reach-
ing appropriate coverage determinations 
for new mental health or substance use 
disorder treatments, such as evidence- 
based early intervention programs for indi-
viduals with a serious mental illness and 
types of medical management techniques; 
‘‘(viii) examples of methods of reach-
ing appropriate coverage determinations 
for which there is an indirect relationship 
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between the covered mental health or sub-
stance use disorder benefit and a tradi-
tional covered medical and surgical benefit, 
such as residential treatment or hos-
pitalizations involving voluntary or involun-
tary commitment; and 
‘‘(ix) additional illustrative examples 
of methods, processes, strategies, evi-
dentiary standards, and other factors for 
which the Secretary determines that addi-
tional guidance is necessary to improve 
compliance 
with 
this 
section, 
section 
2799A–1 of the Public Health Service Act, 
or section 9812 of the Internal Revenue 
Code of 1986, as applicable. 
‘‘(D) PUBLIC COMMENT.—Prior to issuing 
any final guidance under this paragraph, the 
Secretary shall provide a public comment period 
of not less than 60 days during which any 
member of the public may provide comments on 
a draft of the guidance. 
‘‘(8) COMPLIANCE REQUIREMENTS.— 
‘‘(A) NONQUANTITATIVE TREATMENT LIM-
ITATION
(NQTL)
REQUIREMENTS.—Beginning 
45 days after the date of enactment of this 
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paragraph, in the case of a group health plan 
or a health insurance issuer offering group 
health insurance coverage that provides both 
medical and surgical benefits and mental health 
or substance use disorder benefits and that im-
poses nonquantitative treatment limitations (re-
ferred to in this section as ‘NQTL’) on mental 
health or substance use disorder benefits, the 
plan or issuer offering health insurance cov-
erage shall perform comparative analyses of the 
design and application of NQTLs in accordance 
with subparagraph (B), and make available to 
the applicable State authority (or, as applicable, 
the Secretary), upon request, the following in-
formation: 
‘‘(i) The specific plan or coverage 
terms regarding the NQTL, that applies to 
such plan or coverage, and a description of 
all mental health or substance use disorder 
and medical or surgical benefits to which it 
applies in each respective benefits classi-
fication. 
‘‘(ii) The factors used to determine 
that the NQTL will apply to mental health 
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or substance use disorder benefits and 
medical or surgical benefits. 
‘‘(iii) The evidentiary standards used 
for the factors identified in clause (ii), 
when applicable, provided that every factor 
shall be defined and any other source or 
evidence relied upon to design and apply 
the NQTL to mental health or substance 
use disorder benefits and medical or sur-
gical benefits. 
‘‘(iv) The comparative analyses dem-
onstrating that the processes, strategies, 
evidentiary standards, and other factors 
used to design the NQTL, as written, and 
the operation processes and strategies as 
written and in operation that are used to 
apply the NQTL for mental health or sub-
stance use disorder benefits are com-
parable to, and are applied no more strin-
gently than, the processes, strategies, evi-
dentiary standards, and other factors used 
to design the NQTL, as written, and the 
operation processes and strategies as writ-
ten and in operation that are used to apply 
the NQTL to medical or surgical benefits. 
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‘‘(v) A disclosure of the specific find-
ings and conclusions reached by the plan 
or coverage that the results of the analyses 
described in this subparagraph indicate 
that the plan or coverage is in compliance 
with this section. 
‘‘(B) SECRETARY REQUEST PROCESS.— 
‘‘(i) SUBMISSION
UPON
REQUEST.— 
The Secretary shall request that a group 
health plan or a health insurance issuer of-
fering group health insurance coverage 
submit the comparative analyses described 
in subparagraph (A) for plans that involve 
potential violations of this section or com-
plaints regarding noncompliance with this 
section that concern NQTLs and any other 
instances in which the Secretary deter-
mines appropriate. The Secretary shall re-
quest not fewer than 20 such analyses per 
year. 
‘‘(ii) ADDITIONAL INFORMATION.—In 
instances in which the Secretary has con-
cluded that the plan or coverage has not 
submitted sufficient information for the 
Secretary to review the comparative anal-
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yses described in subparagraph (A), as re-
quested under clause (i), the Secretary 
shall specify to the plan or coverage the in-
formation the plan or coverage must sub-
mit to be responsive to the request under 
clause (i) for the Secretary to review the 
comparative analyses described in subpara-
graph (A) for compliance with this section. 
Nothing in this paragraph shall require the 
Secretary to conclude that a plan is in 
compliance with this section solely based 
upon the inspection of the comparative 
analyses described in subparagraph (A), as 
requested under clause (i). 
‘‘(iii) REQUIRED ACTION.— 
‘‘(I) IN GENERAL.—In instances 
in which the Secretary has reviewed 
the comparative analyses described in 
subparagraph (A), as requested under 
clause (i), and determined that the 
plan or coverage is not in compliance 
with this section, the plan or cov-
erage— 
‘‘(aa) shall specify to the 
Secretary the actions the plan or 
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coverage will take to be in com-
pliance with this section and pro-
vide to the Secretary comparative 
analyses described in subpara-
graph (A) that demonstrate com-
pliance with this section not later 
than 45 days after the initial de-
termination by the Secretary that 
the plan or coverage is not in 
compliance; and 
‘‘(bb) following the 45-day 
corrective action period under 
item (aa), if the Secretary deter-
mines that the plan or coverage 
still is not in compliance with 
this section, not later than 7 
days after such determination, 
shall notify all individuals en-
rolled in the plan or coverage 
that the plan or coverage has 
been determined to be not in 
compliance with this section. 
‘‘(II) EXEMPTION FROM DISCLO-
SURE.—Documents 
or 
communica-
tions produced in connection with the 
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Secretary’s recommendations to the 
plan or coverage shall not be subject 
to disclosure pursuant to section 552 
of title 5, United States Code. 
‘‘(iv) REPORT.—Not later than 1 year 
after the date of enactment of this para-
graph, and not later than October 1 of 
each year thereafter, the Secretary shall 
submit to Congress, and make publicly 
available, a report that contains— 
‘‘(I) a summary of the compara-
tive analyses requested under clause 
(i), including the identity of each plan 
or coverage that is determined to be 
not in compliance after the final de-
termination by the Secretary de-
scribed in clause (iii)(I)(bb); 
‘‘(II) the Secretary’s conclusions 
as to whether each plan or coverage 
submitted sufficient information for 
the Secretary to review the compara-
tive analyses requested under clause 
(i) for compliance with this section; 
‘‘(III) for each plan or coverage 
that did submit sufficient information 
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‘‘(i) IN
GENERAL.—The Secretary 
shall include instances of noncompliance 
that the Secretary discovers upon review-
ing the comparative analyses requested 
under subparagraph (B)(i) in the compli-
ance program guidance document de-
scribed in paragraph (6), as it is updated 
every 2 years, except that such instances 
shall not disclose any protected health in-
formation or individually identifiable infor-
mation. 
‘‘(ii) GUIDANCE AND REGULATIONS.— 
Not later than 18 months after the date of 
enactment of this paragraph, the Secretary 
shall finalize any draft or interim guidance 
and regulations relating to mental health 
parity under this section. Such draft guid-
ance shall include guidance to clarify the 
process and timeline for current and poten-
tial participants and beneficiaries (and au-
thorized representatives and health care 
providers of such participants and bene-
ficiaries) with respect to plans to file com-
plaints of such plans or issuers being in 
violation of this section, including guid-
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ance, by plan type, on the relevant State, 
regional, or national office with which such 
complaints should be filed. 
‘‘(iii) STATE.—The Secretary shall 
share information on findings of compli-
ance and noncompliance discovered upon 
reviewing the comparative analyses re-
quested under subparagraph (B)(i) with 
the State where the group health plan is 
located or the State where the health in-
surance issuer is licensed to do business 
for coverage offered by a health insurance 
issuer in the group market, in accordance 
with paragraph (6)(B)(iii)(II).’’. 
(c) IRC.—Section 9812 of the Internal Revenue Code 
of 1986 is amended by adding at the end the following 
new paragraphs: 
‘‘(6) COMPLIANCE PROGRAM GUIDANCE DOCU-
MENT.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the date of enactment of the 
Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
of Labor, and the Secretary of Health and 
Human Services, in consultation with the In-
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spector General of the Department of Health 
and Human Services, the Inspector General of 
the Department of Labor, and the Inspector 
General of the Department of the Treasury, 
shall issue a compliance program guidance doc-
ument to help improve compliance with this sec-
tion, section 712 of the Employee Retirement 
Income Security Act of 1974, and section 
2799A–1 of the Public Health Service Act, as 
applicable. In carrying out this paragraph, the 
Secretaries may take into consideration the 
2016 publication of the Department of Health 
and Human Services and the Department of 
Labor, entitled ‘Warning Signs - Plan or Policy 
Non-Quantitative 
Treatment 
Limitations 
(NQTLs) that Require Additional Analysis to 
Determine Mental Health Parity Compliance’. 
‘‘(B) EXAMPLES
ILLUSTRATING
COMPLI-
ANCE AND NONCOMPLIANCE.— 
‘‘(i) IN
GENERAL.—The compliance 
program 
guidance 
document 
required 
under this paragraph shall provide illus-
trative, de-identified examples (that do not 
disclose any protected health information 
or individually identifiable information) of 
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previous findings of compliance and non-
compliance with this section, section 712 of 
the Employee Retirement Income Security 
Act of 1974, or section 2799A–1 of the 
Public Health Service Act, as applicable, 
based on investigations of violations of 
such sections, including— 
‘‘(I) examples illustrating re-
quirements for information disclosures 
and nonquantitative treatment limita-
tions; and 
‘‘(II) descriptions of the viola-
tions uncovered during the course of 
such investigations. 
‘‘(ii) NONQUANTITATIVE TREATMENT 
LIMITATIONS.—To the extent that any ex-
ample described in clause (i) involves a 
finding of compliance or noncompliance 
with regard to any requirement for non-
quantitative treatment limitations, the ex-
ample shall provide sufficient detail to fully 
explain such finding, including a full de-
scription of the criteria involved for ap-
proving medical and surgical benefits and 
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the criteria involved for approving mental 
health and substance use disorder benefits. 
‘‘(iii) ACCESS TO ADDITIONAL INFOR-
MATION REGARDING COMPLIANCE.—In de-
veloping and issuing the compliance pro-
gram guidance document required under 
this paragraph, the Secretaries specified in 
subparagraph (A)— 
‘‘(I) shall enter into interagency 
agreements with the Inspector Gen-
eral of the Department of Health and 
Human Services, the Inspector Gen-
eral of the Department of Labor, and 
the Inspector General of the Depart-
ment of the Treasury to share find-
ings of compliance and noncompliance 
with this section, section 712 of the 
Employee Retirement Income Security 
Act of 1974, or section 2799A–1 of 
the Public Health Service Act, as ap-
plicable; and 
‘‘(II) shall seek to enter into an 
agreement with a State to share infor-
mation on findings of compliance and 
noncompliance with this section, sec-
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tion 712 of the Employee Retirement 
Income Security Act of 1974, or sec-
tion 2799A–1 of the Public Health 
Service Act, as applicable. 
‘‘(C) RECOMMENDATIONS.—The compli-
ance program guidance document shall include 
recommendations to advance compliance with 
this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 2799A–1 of the Public Health Service Act, 
as applicable, and encourage the development 
and use of internal controls to monitor adher-
ence to applicable statutes, regulations, and 
program requirements. Such internal controls 
may include illustrative examples of non-
quantitative treatment limitations on mental 
health and substance use disorder benefits, 
which may fail to comply with this section, sec-
tion 712 of the Employee Retirement Income 
Security Act of 1974, or section 2799A–1 of 
the Public Health Service Act, as applicable, in 
relation to nonquantitative treatment limita-
tions on medical and surgical benefits. 
‘‘(D) UPDATING
THE
COMPLIANCE
PRO-
GRAM GUIDANCE DOCUMENT.—The Secretary, 
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the Secretary of Labor, and the Secretary of 
Health and Human Services, in consultation 
with the Inspector General of the Department 
of Health and Human Services, the Inspector 
General of the Department of Labor, and the 
Inspector General of the Department of the 
Treasury, shall update the compliance program 
guidance document every 2 years to include il-
lustrative, de-identified examples (that do not 
disclose any protected health information or in-
dividually identifiable information) of previous 
findings of compliance and noncompliance with 
this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 2799A–1 of the Public Health Service Act, 
as applicable. 
‘‘(7) ADDITIONAL GUIDANCE.— 
‘‘(A) IN
GENERAL.—Not later than 12 
months after the date of enactment of the 
Helping Families in Mental Health Crisis Re-
form Act of 2016, the Secretary, the Secretary 
of Labor, and the Secretary of Health and 
Human Services shall issue guidance to group 
health plans and health insurance issuers offer-
ing group or individual health insurance cov-
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erage to assist such plans and issuers in satis-
fying the requirements of this section, section 
712 of the Employee Retirement Income Secu-
rity Act of 1974, or section 2799A–1 of the 
Public Health Service Act, as applicable. 
‘‘(B) DISCLOSURE.— 
‘‘(i) GUIDANCE
FOR
PLANS
AND 
ISSUERS.—The guidance issued under this 
paragraph shall include clarifying informa-
tion and illustrative examples of methods 
that group health plans and health insur-
ance issuers offering group or individual 
health insurance coverage may use for dis-
closing information to ensure compliance 
with the requirements under this section, 
section 712 of the Employee Retirement 
Income Security Act of 1974, or section 
2799A–1 of the Public Health Service Act 
(and any regulations promulgated pursu-
ant to such sections, as applicable). 
‘‘(ii) DOCUMENTS FOR PARTICIPANTS, 
BENEFICIARIES, CONTRACTING PROVIDERS, 
OR AUTHORIZED REPRESENTATIVES.—The 
guidance issued under this paragraph shall 
include clarifying information and illus-
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trative examples of methods that group 
health plans and health insurance issuers 
offering group or individual health insur-
ance coverage may use to provide any par-
ticipant, beneficiary, contracting provider, 
or authorized representative, as applicable, 
with documents containing information 
that the health plans or issuers are re-
quired to disclose to participants, bene-
ficiaries, contracting providers, or author-
ized representatives to ensure compliance 
with this section, section 712 of the Em-
ployee Retirement Income Security Act of 
1974, or section 2799A–1 of the Public 
Health Service Act, as applicable, compli-
ance with any regulation issued pursuant 
to such respective section, or compliance 
with any other applicable law or regula-
tion. Such guidance shall include informa-
tion that is comparative in nature with re-
spect to— 
‘‘(I) nonquantitative treatment 
limitations for both medical and sur-
gical benefits and mental health and 
substance use disorder benefits; 
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‘‘(II) the processes, strategies, 
evidentiary standards, and other fac-
tors used to apply the limitations de-
scribed in subclause (I); and 
‘‘(III) the application of the limi-
tations described in subclause (I) to 
ensure that such limitations are ap-
plied in parity with respect to both 
medical and surgical benefits and 
mental health and substance use dis-
order benefits. 
‘‘(C) NONQUANTITATIVE TREATMENT LIM-
ITATIONS.—The guidance issued under this 
paragraph shall include clarifying information 
and illustrative examples of methods, processes, 
strategies, evidentiary standards, and other fac-
tors that group health plans and health insur-
ance issuers offering group or individual health 
insurance coverage may use regarding the de-
velopment and application of nonquantitative 
treatment limitations to ensure compliance with 
this section, section 712 of the Employee Re-
tirement Income Security Act of 1974, or sec-
tion 2799A–1 of the Public Health Service Act, 
as applicable (and any regulations promulgated 
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pursuant to such respective section), includ-
ing— 
‘‘(i) examples of methods of deter-
mining appropriate types of nonquantita-
tive treatment limitations with respect to 
both medical and surgical benefits and 
mental health and substance use disorder 
benefits, including nonquantitative treat-
ment limitations pertaining to— 
‘‘(I) medical management stand-
ards based on medical necessity or ap-
propriateness, or whether a treatment 
is experimental or investigative; 
‘‘(II) limitations with respect to 
prescription drug formulary design; 
and 
‘‘(III) use of fail-first or step 
therapy protocols; 
‘‘(ii) examples of methods of deter-
mining— 
‘‘(I) network admission standards 
(such as credentialing); and 
‘‘(II) factors used in provider re-
imbursement methodologies (such as 
service type, geographic market, de-
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mand for services, and provider sup-
ply, practice size, training, experience, 
and licensure) as such factors apply to 
network adequacy; 
‘‘(iii) examples of sources of informa-
tion that may serve as evidentiary stand-
ards for the purposes of making deter-
minations regarding the development and 
application of nonquantitative treatment 
limitations; 
‘‘(iv) examples of specific factors, and 
the evidentiary standards used to evaluate 
such factors, used by such plans or issuers 
in performing a nonquantitative treatment 
limitation analysis; 
‘‘(v) examples of how specific evi-
dentiary standards may be used to deter-
mine whether treatments are considered 
experimental or investigative; 
‘‘(vi) examples of how specific evi-
dentiary standards may be applied to each 
service category or classification of bene-
fits; 
‘‘(vii) examples of methods of reach-
ing appropriate coverage determinations 
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for new mental health or substance use 
disorder treatments, such as evidence- 
based early intervention programs for indi-
viduals with a serious mental illness and 
types of medical management techniques; 
‘‘(viii) examples of methods of reach-
ing appropriate coverage determinations 
for which there is an indirect relationship 
between the covered mental health or sub-
stance use disorder benefit and a tradi-
tional covered medical and surgical benefit, 
such as residential treatment or hos-
pitalizations involving voluntary or involun-
tary commitment; and 
‘‘(ix) additional illustrative examples 
of methods, processes, strategies, evi-
dentiary standards, and other factors for 
which the Secretary determines that addi-
tional guidance is necessary to improve 
compliance with this section, section 712 of 
the Employee Retirement Income Security 
Act of 1974, or section 2799A–1 of the 
Public Health Service Act, as applicable. 
‘‘(D) PUBLIC COMMENT.—Prior to issuing 
any final guidance under this paragraph, the 
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Secretary shall provide a public comment period 
of not less than 60 days during which any 
member of the public may provide comments on 
a draft of the guidance. 
‘‘(8) COMPLIANCE REQUIREMENTS.— 
‘‘(A) NONQUANTITATIVE TREATMENT LIM-
ITATION
(NQTL)
REQUIREMENTS.—Beginning 
45 days after the date of enactment of this 
paragraph, in the case of a group health plan 
that provides both medical and surgical benefits 
and mental health or substance use disorder 
benefits and that imposes nonquantitative treat-
ment limitations (referred to in this section as 
‘NQTL’) on mental health or substance use dis-
order benefits, the plan shall perform compara-
tive analyses of the design and application of 
NQTLs in accordance with subparagraph (B), 
and make available to the applicable State au-
thority (or, as applicable, the Secretary), upon 
request, the following information: 
‘‘(i) The specific plan terms regarding 
the NQTL, that applies to such plan or 
coverage, and a description of all mental 
health or substance use disorder and med-
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ical or surgical benefits to which it applies 
in each respective benefits classification. 
‘‘(ii) The factors used to determine 
that the NQTL will apply to mental health 
or substance use disorder benefits and 
medical or surgical benefits. 
‘‘(iii) The evidentiary standards used 
for the factors identified in clause (ii), 
when applicable, provided that every factor 
shall be defined and any other source or 
evidence relied upon to design and apply 
the NQTL to mental health or substance 
use disorder benefits and medical or sur-
gical benefits. 
‘‘(iv) The comparative analyses dem-
onstrating that the processes, strategies, 
evidentiary standards, and other factors 
used to design the NQTL, as written, and 
the operation processes and strategies as 
written and in operation that are used to 
apply the NQTL for mental health or sub-
stance use disorder benefits are com-
parable to, and are applied no more strin-
gently than, the processes, strategies, evi-
dentiary standards, and other factors used 
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to design the NQTL, as written, and the 
operation processes and strategies as writ-
ten and in operation that are used to apply 
the NQTL to medical or surgical benefits. 
‘‘(v) A disclosure of the specific find-
ings and conclusions reached by the plan 
that the results of the analyses described 
in this subparagraph indicate that the plan 
is in compliance with this section. 
‘‘(B) SECRETARY REQUEST PROCESS.— 
‘‘(i) SUBMISSION
UPON
REQUEST.— 
The Secretary shall request that a group 
health plan submit the comparative anal-
yses described in subparagraph (A) for 
plans that involve potential violations of 
this section or complaints regarding non-
compliance with this section that concern 
NQTLs and any other instances in which 
the Secretary determines appropriate. The 
Secretary shall request not fewer than 20 
such analyses per year. 
‘‘(ii) ADDITIONAL INFORMATION.—In 
instances in which the Secretary has con-
cluded that the plan has not submitted suf-
ficient information for the Secretary to re-
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view the comparative analyses described in 
subparagraph (A), as requested under 
clause (i), the Secretary shall specify to the 
plan the information the plan or coverage 
must submit to be responsive to the re-
quest under clause (i) for the Secretary to 
review the comparative analyses described 
in subparagraph (A) for compliance with 
this section. Nothing in this paragraph 
shall require the Secretary to conclude that 
a plan is in compliance with this section 
solely based upon the inspection of the 
comparative analyses described in subpara-
graph (A), as requested under clause (i). 
‘‘(iii) REQUIRED ACTION.— 
‘‘(I) IN GENERAL.—In instances 
in which the Secretary has reviewed 
the comparative analyses described in 
subparagraph (A), as requested under 
clause (i), and determined that the 
plan is not in compliance with this 
section, the plan— 
‘‘(aa) shall specify to the 
Secretary the actions the plan 
will take to be in compliance with 
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this section and provide to the 
Secretary comparative analyses 
described in subparagraph (A) 
that demonstrate compliance with 
this section not later than 45 
days after the initial determina-
tion by the Secretary that the 
plan is not in compliance; and 
‘‘(bb) following the 45-day 
corrective action period under 
item (aa), if the Secretary deter-
mines that the plan still is not in 
compliance with this section, not 
later than 7 days after such de-
termination, shall notify all indi-
viduals enrolled in the plan or 
coverage that the plan has been 
determined to be not in compli-
ance with this section. 
‘‘(II) EXEMPTION FROM DISCLO-
SURE.—Documents 
or 
communica-
tions produced in connection with the 
Secretary’s recommendations to the 
plan or coverage shall not be subject 
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