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 pay-
ment 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 the plan administrator (or 
the health insurance issuer offering such 
coverage) to the participant or bene-
ficiary.’’. 
(d) MINIMUM
BENEFIT
REQUIREMENTS.— 
Subsection (a) of such section is further 
amended by adding at the end the following 
new paragraph: 
‘‘(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-
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smartinez on PRODPC61 with BILLS
ance coverage offered in connection 
with such a plan) that provides any 
mental health and substance-related 
disorder benefits, the plan or cov-
erage shall include benefits for any 
mental health condition or substance- 
related disorder for which benefits 
are provided under the benefit plan 
option offered under chapter 89 of 
title 5, United States Code, with the 
highest average enrollment as of the 
beginning of the most recent year be-
ginning 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 pro-
vides both medical and surgical 
benefits and mental health and 
substance-related disorder bene-
fits, if medical and surgical bene-
fits are provided for substantially 
all items and services in a cat-
egory specified in clause (ii) fur-
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nished outside any network of 
providers established or recog-
nized under such plan or cov-
erage, the mental health and sub-
stance-related disorder benefits 
shall also be provided for items 
and services in such category fur-
nished outside any network of 
providers established or recog-
nized under such plan or cov-
erage in accordance with the re-
quirements of this section. 
‘‘(ii) CATEGORIES OF ITEMS AND 
SERVICES.—For purposes of clause 
(i), there shall be the following 
three categories of items and 
services 
for 
benefits, 
whether 
medical and surgical benefits or 
mental health and substance-re-
lated disorder benefits, and all 
medical and surgical benefits and 
all mental health and substance- 
related disorder benefits shall be 
classified into one of the fol-
lowing categories: 
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‘‘(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 
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 
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smartinez on PRODPC61 with BILLS
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 
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 
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smartinez on PRODPC61 with BILLS
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 
in-
creases in actual costs under a plan 
(or coverage) for purposes of this sub-
section 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 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. 
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‘‘(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— 
(1) by inserting ‘‘(or 1 in the case of 
an employer residing in a State that per-
mits 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-
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smartinez on PRODPC61 with BILLS
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 
greater than the protections, benefits, 
methods of access to benefits, rights or 
remedies provided under this section. 
‘‘(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.’’. 
(2) CLERICAL
AMENDMENT.—The table 
of contents in section 1 of such Act is 
amended by striking the item relating to 
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smartinez on PRODPC61 with BILLS
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-
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 (speci-
fied in subparagraph (C)), the plan or 
coverage may not impose any treat-
ment limit on mental health and sub-
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smartinez on PRODPC61 with BILLS
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 
surgical benefits in any category of 
items or services, the plan or cov-
erage may not impose such a treat-
ment limit on mental health and sub-
stance-related disorder benefits for 
items and services within such cat-
egory that are more restrictive than 
the predominant treatment limit that 
is applicable to medical and surgical 
benefits for items and services within 
such category. 
‘‘(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 ben-
efits, whether medical and surgical 
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smartinez on PRODPC61 with BILLS
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 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. 
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smartinez on PRODPC61 with BILLS
‘‘(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. 
‘‘(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, num-
ber of visits or days of coverage, or 
other similar limit on the duration or 
scope of treatment under the plan or 
coverage. 
‘‘(E) 
PREDOMINANCE.—For 
pur-
poses of this subsection, a treatment 
limit or financial requirement with 
respect to a category of items and 
services is considered to be predomi-
nant if it is the most common or fre-
quent of such type of limit or require-
ment with respect to such category of 
items and services. 
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‘‘(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 
medical and surgical benefits within 
a category of items and services 
(specified in paragraph (3)(C)), the 
plan or coverage may not impose 
such a beneficiary financial require-
ment on mental health and sub-
stance-related disorder benefits for 
items and services within such cat-
egory. 
‘‘(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 
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smartinez on PRODPC61 with BILLS
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, 
the plan or coverage shall apply 
such requirement (or, if there is 
more than one such requirement 
for such category of items and 
services, 
the 
predominant 
re-
quirement for such category) both 
to medical and surgical benefits 
within such category and to men-
tal health and substance-related 
disorder benefits within such cat-
egory and shall not distinguish in 
the application of such require-
ment between such medical and 
surgical benefits and such mental 
health and substance-related dis-
order benefits. 
‘‘(ii) OTHER FINANCIAL REQUIRE-
MENTS.—If the plan or coverage 
includes a beneficiary financial 
requirement 
not 
described 
in 
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smartinez on PRODPC61 with BILLS
clause (i) on substantially all med-
ical and surgical benefits within a 
category of items and services, 
the plan or coverage may not im-
pose such financial requirement 
on mental health and substance- 
related disorder benefits for items 
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 
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smartinez on PRODPC61 with BILLS
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 requir-
ing’’ and inserting ‘‘construed as re-
quiring’’; 
(B) by striking ‘‘; or’’ and insert-
ing a period; and 
(C) by striking paragraph (2). 
(b) EXPANSION TO SUBSTANCE-RELATED DIS-
ORDER
BENEFITS
AND
REVISION
OF
DEFINI-
TION.—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’’; 
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smartinez on PRODPC61 with BILLS
(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-
ment of substances abuse or chemical 
dependency’’. 
(c) AVAILABILITY
OF
PLAN
INFORMATION 
ABOUT
CRITERIA
FOR
MEDICAL
NECESSITY.— 
Subsection (a) of such section, as amended by 
subsection (a)(1), is further amended by add-
ing 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 
insurance 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, 
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smartinez on PRODPC61 with BILLS
or contracting provider upon request. 
The reason for any denial under the plan 
(or coverage) of reimbursement or pay-
ment 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 the plan administrator (or 
the health insurance issuer offering such 
coverage) to the participant or bene-
ficiary.’’. 
(d) MINIMUM
BENEFIT
REQUIREMENTS.— 
Subsection (a) of such section is further 
amended by adding at the end the following 
new paragraph: 
‘‘(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 cov-
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smartinez on PRODPC61 with BILLS
erage shall include benefits for any 
mental health condition or substance- 
related disorder for which benefits 
are provided under the benefit plan 
option offered under chapter 89 of 
title 5, United States Code, with the 
highest average enrollment as of the 
beginning of the most recent year be-
ginning 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 pro-
vides both medical and surgical 
benefits and mental health and 
substance-related disorder bene-
fits, if medical and surgical bene-
fits are provided for substantially 
all items and services in a cat-
egory specified in clause (ii) fur-
nished outside any network of 
providers established or recog-
nized under such plan or cov-
erage, the mental health and sub-
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smartinez on PRODPC61 with BILLS
stance-related disorder benefits 
shall also be provided for items 
and services in such category fur-
nished outside any network of 
providers established or recog-
nized under such plan or cov-
erage in accordance with the re-
quirements of this section. 
‘‘(ii) CATEGORIES OF ITEMS AND 
SERVICES.—For purposes of clause 
(i), there shall be the following 
three categories of items and 
services 
for 
benefits, 
whether 
medical and surgical benefits or 
mental health and substance-re-
lated disorder benefits, and all 
medical and surgical benefits and 
all mental health and substance- 
related disorder benefits shall be 
classified into one of the fol-
lowing categories: 
‘‘(I) 
EMERGENCY.—Items 
and 
services, 
whether 
fur-
nished on an inpatient or out-
patient basis, required for the 
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smartinez on PRODPC61 with BILLS
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 
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-
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smartinez on PRODPC61 with BILLS
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 
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. 
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‘‘(C) 
DETERMINATIONS
BY
ACTU-
ARIES.—Determinations 
as 
to 
in-
creases in actual costs under a plan 
(or coverage) for purposes of this sub-
section 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 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.—A 
group 
health plan under this part shall com-
ply 
with 
the 
notice 
requirement 
under section 712(c)(2)(E) of the Em-
ployee Retirement Income Security 
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smartinez on PRODPC61 with BILLS
Act of 1974 with respect to the a 
modification of mental health and 
substance-related disorder benefits as 
permitted under this paragraph as if 
such section applied to such plan.’’. 
(f) CHANGE IN EXCLUSION FOR SMALLEST EM-
PLOYERS.—Subsection (c)(1)(B) of such section 
is amended— 
(1) by inserting ‘‘(or 1 in the case of 
an employer residing in a State that per-
mits 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.— 
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smartinez on PRODPC61 with BILLS
‘‘(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 
greater than the protections, benefits, 
methods of access to benefits, rights or 
remedies provided under this section. 
‘‘(2) CONSTRUCTION.—Nothing in this 
section shall be construed to affect or 
modify the provisions of section 2723 
with respect to group health plans.’’. 
(i) CONFORMING AMENDMENT TO HEADING.— 
The heading of such section is amended to 
read as follows: 
‘‘SEC. 2705.’’. 
(j) EFFECTIVE
DATE.—The amendments 
made by this section shall apply with respect 
to plan years beginning on or after January 
1, 2008. 
SEC. 4. AMENDMENTS TO THE INTERNAL REVENUE CODE 
OF 1986. 
(a) EXTENSION
OF PARITY
TO TREATMENT 
LIMITS AND BENEFICIARY FINANCIAL REQUIRE-
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smartinez on PRODPC61 with BILLS
MENTS.—Section 9812 of the Internal Revenue 
Code of 1986 is amended— 
(1) in subsection (a), by adding at the 
end the following new paragraphs: 
‘‘(3) TREATMENT LIMITS.—In the case of 
a group health plan that provides both 
medical and surgical benefits and mental 
health or substance-related disorder ben-
efits— 
‘‘(A) NO TREATMENT LIMIT.—If the 
plan does not include a treatment 
limit (as defined in subparagraph (D)) 
on substantially all medical and sur-
gical benefits in any category of items 
or services (specified in subpara-
graph (C)), the plan may not impose 
any treatment limit on mental health 
or substance-related disorder benefits 
that are classified in the same cat-
egory of items or services. 
‘‘(B) TREATMENT LIMIT.—If the plan 
includes a treatment limit on sub-
stantially all medical and surgical 
benefits in any category of items or 
services, the plan may not impose 
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such a treatment limit on mental 
health or substance-related disorder 
benefits for items and services within 
such category that is more restrictive 
than the predominant treatment limit 
that is applicable to medical and sur-
gical benefits for items and services 
within such category. 
‘‘(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 ben-
efits, 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-
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patient basis and within a net-
work of providers established or 
recognized under such plan. 
‘‘(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. 
‘‘(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. 
‘‘(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. 
‘‘(v) EMERGENCY
CARE.—Items 
and services, whether furnished 
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on an inpatient or outpatient 
basis or within or outside any 
network of providers, required 
for the treatment of an emer-
gency medical condition (includ-
ing an emergency condition relat-
ing to mental health or substance- 
related disorders). 
‘‘(D) TREATMENT
LIMIT
DEFINED.— 
For purposes of this paragraph, the 
term ‘treatment limit’ means, with re-
spect to a plan, limitation on the fre-
quency of treatment, number of visits 
or days of coverage, or other similar 
limit on the duration or scope of 
treatment under the plan. 
‘‘(E) 
PREDOMINANCE.—For 
pur-
poses of this subsection, a treatment 
limit or financial requirement with 
respect to a category of items and 
services is considered to be predomi-
nant if it is the most common or fre-
quent of such type of limit or require-
ment with respect to such category of 
items and services. 
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‘‘(4) BENEFICIARY
FINANCIAL
REQUIRE-
MENTS.—In the case of a group health 
plan that provides both medical and sur-
gical benefits and mental health or sub-
stance-related disorder benefits— 
‘‘(A) NO BENEFICIARY FINANCIAL RE-
QUIREMENT.—If the plan does not in-
clude a beneficiary financial require-
ment (as defined in subparagraph 
(C)) on substantially all medical and 
surgical benefits within a category of 
items and services (specified in para-
graph (3)(C)), the plan may not im-
pose such a beneficiary financial re-
quirement on mental health or sub-
stance-related disorder benefits for 
items and services within such cat-
egory. 
‘‘(B) BENEFICIARY
FINANCIAL
RE-
QUIREMENT.— 
‘‘(i) 
TREATMENT
OF 
DEDUCTIBLES, OUT-OF-POCKET
LIM-
ITS, 
AND
SIMILAR
FINANCIAL
RE-
QUIREMENTS.—If the plan includes 
a deductible, a limitation on out- 
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of-pocket 
expenses, 
or 
similar 
beneficiary financial requirement 
that does not apply separately to 
individual items and services on 
substantially all medical and sur-
gical benefits within a category of 
items and services, the plan shall 
apply such requirement (or, if 
there is more than one such re-
quirement for such category of 
items and services, the predomi-
nant requirement for such cat-
egory) both to medical and sur-
gical benefits within such cat-
egory 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 includes a 
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beneficiary financial requirement 
not described in clause (i) on sub-
stantially all medical and surgical 
benefits within a category of 
items and services, the plan may 
not impose such financial re-
quirement on mental health or 
substance-related disorder bene-
fits for items and services within 
such category in a way that re-
sults in greater out-of-pocket ex-
penses to the participant or bene-
ficiary than the predominant ben-
eficiary financial requirement ap-
plicable to medical and surgical 
benefits for items and services 
within such category. 
‘‘(iii) CONSTRUCTION.—Nothing 
in this subparagraph shall be con-
strued as prohibiting the plan 
from waiving the application of 
any deductible for mental health 
benefits or substance-related dis-
order benefits or both. 
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‘‘(C) BENEFICIARY
FINANCIAL
RE-
QUIREMENT DEFINED.—For purposes of 
this paragraph, the term ‘beneficiary 
financial requirement’ includes, with 
respect to a plan, any deductible, co-
insurance, 
co-payment, 
other 
cost 
sharing, and limitation on the total 
amount that may be paid by a partici-
pant or beneficiary with respect to 
benefits under the plan, but does not 
include the application of any aggre-
gate lifetime limit or annual limit.’’, 
and 
(2) in subsection (b)— 
(A) by striking ‘‘construed—’’ and 
all that follows through ‘‘(1) as requir-
ing’’ and inserting ‘‘construed as re-
quiring’’, 
(B) by striking ‘‘; or’’ and insert-
ing a period, and 
(C) by striking paragraph (2). 
(b) EXPANSION TO SUBSTANCE-RELATED DIS-
ORDER
BENEFITS
AND
REVISION
OF
DEFINI-
TION.—Section 9812 of such Code is further 
amended— 
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(1) by striking ‘‘mental health bene-
fits’’ each place it appears (other than in 
any provision amended by paragraph (2)) 
and inserting ‘‘mental health or sub-
stance-related disorder benefits’’, 
(2) by striking ‘‘mental health bene-
fits’’ each place it appears in subsections 
(a)(1)(B)(i), 
(a)(1)(C), 
(a)(2)(B)(i), 
and 
(a)(2)(C) and inserting ‘‘mental health 
and substance-related disorder benefits’’, 
and 
(3) in subsection (e), by striking para-
graph (4) and inserting the following new 
paragraphs: 
‘‘(4) MENTAL
HEALTH
BENEFITS.—The 
term ‘mental health benefits’ means bene-
fits with respect to services for mental 
health conditions, as defined under the 
terms of the plan, but does not include 
substance-related disorder benefits. 
‘‘(5) 
SUBSTANCE-RELATED
DISORDER 
BENEFITS.—The 
term 
‘substance-related 
disorder benefits’ means benefits with re-
spect to services for substance-related 
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disorders, as defined under the terms of 
the plan.’’. 
(c) AVAILABILITY
OF
PLAN
INFORMATION 
ABOUT
CRITERIA
FOR
MEDICAL
NECESSITY.— 
Subsection (a) of section 9812 of such Code, as 
amended by subsection (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 shall be made 
available by the plan administrator to 
any current or potential participant, ben-
eficiary, or contracting provider upon re-
quest. The reason for any denial under 
the plan of reimbursement or payment 
for services with respect to mental health 
and substance-related disorder benefits 
in the case of any participant or bene-
ficiary shall, upon request, be made avail-
able by the plan administrator to the par-
ticipant or beneficiary.’’. 
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(d) MINIMUM
BENEFIT
REQUIREMENTS.— 
Subsection (a) of section 9812 of such Code is 
further amended by adding at the end the fol-
lowing new paragraph: 
‘‘(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 that provides any 
mental health or substance-related 
disorder benefits, the plan shall in-
clude benefits for any mental health 
condition or substance-related dis-
order included in the most recent edi-
tion of the Diagnostic and Statistical 
Manual of Mental Disorders pub-
lished by the American Psychiatric 
Association. 
‘‘(B) EQUITY IN COVERAGE OF OUT- 
OF-NETWORK BENEFITS.— 
‘‘(i) IN
GENERAL.—In the case 
of a group health plan that pro-
vides both medical and surgical 
benefits and mental health or 
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substance-related disorder bene-
fits, if medical and surgical bene-
fits are provided for substantially 
all items and services in a cat-
egory specified in clause (ii) fur-
nished outside any network of 
providers established or recog-
nized under such plan, 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 in accordance with the re-
quirements of this section. 
‘‘(ii) CATEGORIES OF ITEMS AND 
SERVICES.—For purposes of clause 
(i), there shall be the following 
three categories of items and 
services 
for 
benefits, 
whether 
medical and surgical benefits or 
mental health and substance-re-
lated disorder benefits, and all 
medical and surgical benefits and 
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all mental health and substance- 
related disorder benefits shall be 
classified into one of the fol-
lowing categories: 
‘‘(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 or sub-
stance-related disorders). 
‘‘(II) 
INPATIENT.—Items 
and services not described in 
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 section 9812(c) of such 
Code is amended to read as follows: 
‘‘(2) INCREASED COST EXEMPTION.— 
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