HR 1424 PCS
disorder benefits in the case of any participant or 
beneficiary shall, on request or as otherwise re-
quired, be made available by the plan administrator 
(or the health insurance issuer offering such cov-
erage) to the participant or beneficiary in accord-
ance with regulations.’’. 
(d) 
MINIMUM
BENEFIT
REQUIREMENTS.—Sub-
section (a) of such section is further amended by adding 
at the end the following new paragraph: 
‘‘(6) MINIMUM SCOPE OF COVERAGE AND EQ-
UITY IN OUT-OF-NETWORK BENEFITS.— 
‘‘(A) 
MINIMUM
SCOPE
OF
MENTAL 
HEALTH AND SUBSTANCE-RELATED DISORDER 
BENEFITS.—In the case of a group health plan 
(or health insurance coverage offered in connec-
tion with such a plan) that provides any mental 
health or substance-related disorder benefits, 
the plan or coverage shall include benefits for 
any mental health condition or substance-re-
lated disorder included in the most recent edi-
tion of the Diagnostic and Statistical Manual of 
Mental Disorders published by the American 
Psychiatric Association. 
‘‘(B) EQUITY
IN
COVERAGE
OF
OUT-OF- 
NETWORK BENEFITS.— 
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‘‘(i) IN GENERAL.—In the case of a 
plan or coverage that provides both med-
ical and surgical benefits and mental 
health or substance-related disorder bene-
fits, if medical and surgical benefits are 
provided for substantially all items and 
services in a category specified in clause 
(ii) furnished outside any network of pro-
viders established or recognized under such 
plan or coverage, the mental health and 
substance-related disorder benefits shall 
also be provided for items and services in 
such category furnished outside any net-
work of providers established or recognized 
under such plan or coverage in accordance 
with the requirements 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-related disorder bene-
fits, and all medical and surgical benefits 
and all mental health and substance-re-
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HR 1424 PCS
lated disorder benefits shall be classified 
into one of the following categories: 
‘‘(I) EMERGENCY.—Items and 
services, whether furnished on an in-
patient or outpatient basis, required 
for the treatment of an emergency 
medical condition (as defined in sec-
tion 1867(e) of the Social Security 
Act, including an emergency condition 
relating 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 EXEMPTION.— 
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 insurance coverage 
offered in connection with such a plan), if the 
application of this section to such plan (or cov-
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HR 1424 PCS
erage) 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 substance-related dis-
order 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 coverage) dur-
ing the following plan year, and such exemption 
shall apply to the plan (or coverage) for 1 plan 
year. 
‘‘(B) APPLICABLE PERCENTAGE.—With re-
spect 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 to which this paragraph applies; 
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 
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HR 1424 PCS
subsection shall be made in writing and pre-
pared and certified by a qualified and licensed 
actuary who is a member in good standing of 
the American Academy of Actuaries. Such de-
terminations shall be made available by the 
plan administrator (or health insurance issuer, 
as the case may be) to the general public. 
‘‘(D) 6-MONTH
DETERMINATIONS.—If a 
group health plan (or a health insurance issuer 
offering coverage in connection with such a 
plan) seeks an exemption under this paragraph, 
determinations under subparagraph (A) shall be 
made after such plan (or coverage) has com-
plied with this section for the first 6 months of 
the plan year involved. 
‘‘(E) NOTIFICATION.—An election to mod-
ify coverage of mental health and substance-re-
lated disorder benefits as permitted under this 
paragraph shall be treated as a material modi-
fication in the terms of the plan as described in 
section 102(a) and notice of which shall be pro-
vided a reasonable period in advance of the 
change. 
‘‘(F) 
NOTIFICATION
OF
APPROPRIATE 
AGENCY.— 
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HR 1424 PCS
‘‘(i) IN
GENERAL.—A group health 
plan that, based on a certification de-
scribed under subparagraph (C), qualifies 
for an exemption under this paragraph, 
and elects to implement the exemption, 
shall notify the Department of Labor of 
such election. 
‘‘(ii) REQUIREMENT.—A notification 
under clause (i) shall include— 
‘‘(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- 
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-re-
lated disorder benefits under the plan; 
and 
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