plied with this section for the first 6 months of 
the plan year involved. 
‘‘(E) NOTIFICATION.—A group health plan 
under this part shall comply with the notice re-
quirement under section 712(c)(2)(E) of the 
Employee Retirement Income Security Act of 
1974 with respect to the a modification of men-
tal health and substance-related disorder bene-
fits as permitted under this paragraph as if 
such section applied to such plan.’’. 
(f) CHANGE IN EXCLUSION FOR SMALLEST EMPLOY-
ERS.—Subsection (c)(1)(B) of such section is amended— 
(1) by inserting ‘‘(or 1 in the case of an em-
ployer residing in a State that permits small groups 
to include a single individual)’’ after ‘‘at least 2’’ the 
first place it appears; and 
(2) by striking ‘‘and who employs at least 2 em-
ployees on the first day of the plan year’’. 
(g) ELIMINATION OF SUNSET PROVISION.—Such sec-
tion is amended by striking out subsection (f). 
(h) CLARIFICATION
REGARDING
PREEMPTION.— 
Such section is further amended by inserting after sub-
section (e) the following new subsection: 
‘‘(f) PREEMPTION, RELATION TO STATE LAWS.— 
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‘‘(1) IN
GENERAL.—Nothing in this section 
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, meth-
ods 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. EQUITY IN MENTAL HEALTH AND SUBSTANCE- 
RELATED DISORDER BENEFITS.’’ 
(j) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning 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 REQUIREMENTS.—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.— 
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‘‘(A) NO TREATMENT LIMIT.—If the plan 
does not include a treatment limit (as defined 
in subparagraph (D)) on substantially all med-
ical and surgical benefits in any category of 
items or services (specified in subparagraph 
(C)), the plan may not impose any treatment 
limit on mental health and substance-related 
disorder benefits that are classified in the same 
category of items or services. 
‘‘(B) TREATMENT LIMIT.—If the plan in-
cludes a treatment limit on substantially all 
medical and surgical benefits in any category of 
items or services, the plan may not impose such 
a treatment limit on mental health and sub-
stance-related disorder benefits for items and 
services within such category that are more re-
strictive than the predominant treatment limit 
that is applicable to medical and surgical bene-
fits for items and services within such category. 
‘‘(C) CATEGORIES
OF
ITEMS
AND
SERV-
ICES FOR APPLICATION OF TREATMENT LIMITS 
AND
BENEFICIARY
FINANCIAL
REQUIRE-
MENTS.—For purposes of this paragraph and 
paragraph (4), there shall be the following four 
categories of items and services for benefits, 
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whether medical and surgical benefits or mental 
health and substance-related disorder benefits, 
and all medical and surgical benefits and all 
mental health and substance related benefits 
shall be classified into one of the following cat-
egories: 
‘‘(i) INPATIENT, IN-NETWORK.—Items 
and services furnished on an inpatient 
basis and within a network of providers es-
tablished or recognized under such plan or 
coverage. 
‘‘(ii) INPATIENT, OUT-OF-NETWORK.— 
Items and services furnished on an inpa-
tient basis and outside any network of pro-
viders established or recognized under such 
plan or coverage. 
‘‘(iii) OUTPATIENT, 
IN-NETWORK.— 
Items and services furnished on an out-
patient basis and within a network of pro-
viders established or recognized under such 
plan or coverage. 
‘‘(iv) 
OUTPATIENT, 
OUT-OF-NET-
WORK.—Items and services furnished on 
an outpatient basis and outside any net-
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work 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 respect to a plan, limitation 
on the frequency of treatment, number of visits 
or days of coverage, or other similar limit on 
the duration or scope of treatment under the 
plan. 
‘‘(E) PREDOMINANCE.—For purposes of 
this subsection, a treatment limit or financial 
requirement with respect to a category of items 
and services is considered to be predominant if 
it is the most common or frequent of such type 
of limit or requirement with respect to such cat-
egory of items and services. 
‘‘(4) 
BENEFICIARY
FINANCIAL
REQUIRE-
MENTS.— 
‘‘(A) NO
BENEFICIARY
FINANCIAL
RE-
QUIREMENT.—If the plan does not include a 
beneficiary financial requirement (as defined in 
subparagraph (C)) on substantially all medical 
and surgical benefits within a category of items 
and services (specified in paragraph (3)(C)), 
the plan may not impose such a beneficiary fi-
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nancial requirement on mental health and sub-
stance-related disorder benefits for items and 
services within such category. 
‘‘(B) BENEFICIARY
FINANCIAL
REQUIRE-
MENT.— 
‘‘(i) TREATMENT
OF
DEDUCTIBLES, 
OUT-OF-POCKET LIMITS, AND SIMILAR FI-
NANCIAL REQUIREMENTS.—If the plan or 
coverage includes a deductible, a limitation 
on out-of-pocket expenses, or similar bene-
ficiary financial requirement that does not 
apply separately to individual items and 
services on substantially all medical 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 pre-
dominant requirement for such category) 
both to medical and surgical benefits with-
in such category and to mental health and 
substance-related disorder benefits within 
such category and shall not distinguish in 
the application of such requirement be-
tween such medical and surgical benefits 
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and such mental health and substance-re-
lated disorder benefits. 
‘‘(ii) OTHER
FINANCIAL
REQUIRE-
MENTS.—If the plan includes a beneficiary 
financial requirement not described in 
clause (i) on substantially all medical and 
surgical benefits within a category of items 
and services, the plan may not impose 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 bene-
ficiary financial requirement applicable to 
medical and surgical benefits for items and 
services within such category. 
‘‘(C) BENEFICIARY
FINANCIAL
REQUIRE-
MENT DEFINED.—For purposes of this para-
graph, the term ‘beneficiary financial require-
ment’ includes, with respect to a plan, 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 respect to benefits under the plan, but 
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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 requiring’’ and insert-
ing ‘‘construed as requiring’’; 
(B) by striking ‘‘; or’’ and inserting a pe-
riod; and 
(C) by striking paragraph (2). 
(b) EXPANSION TO SUBSTANCE-RELATED DISORDER 
BENEFITS AND REVISION OF DEFINITION.—Such section 
is further amended— 
(1) by striking ‘‘mental health benefits’’ and in-
serting ‘‘mental health and substance-related dis-
order benefits’’ each place it appears; and 
(2) in paragraph (4) of subsection (e)— 
(A) by striking ‘‘MENTAL HEALTH BENE-
FITS’’ in the heading and inserting ‘‘MENTAL 
HEALTH AND SUBSTANCE-RELATED DISORDER 
BENEFITS’’; 
(B) by striking ‘‘benefits with respect to 
mental health services’’ and inserting ‘‘benefits 
with respect to services for mental health condi-
tions or substance-related disorders’’; and 
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(C) by striking ‘‘, but does not include 
benefits with respect to treatment 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 adding at the end the following new para-
graph: 
‘‘(5) AVAILABILITY OF PLAN INFORMATION.— 
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 cur-
rent or potential participant, beneficiary, or con-
tracting provider upon request. The reason for any 
denial under the plan of reimbursement or payment 
for services with respect to mental health and sub-
stance-related disorder benefits in the case of any 
participant or beneficiary shall, upon request, be 
made available by the plan administrator to the par-
ticipant or beneficiary.’’. 
(d) 
MINIMUM
BENEFIT
REQUIREMENTS.—Sub-
section (a) of such section is further amended by adding 
at the end the following new paragraph: 
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‘‘(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 and substance-related disorder benefits, 
the plan or coverage shall include benefits for 
any mental health condition or substance-re-
lated 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 begin-
ning of the most recent year beginning 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 that provides both medical and sur-
gical benefits and mental health and sub-
stance-related disorder benefits, if medical 
and surgical benefits are provided for sub-
stantially all items and services in a cat-
egory specified in clause (ii) furnished out-
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side any network of providers 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 fur-
nished outside any network of providers es-
tablished or recognized under such plan 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-
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 (including an emer-
gency condition relating to mental 
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health 
and 
substance-related 
dis-
orders). 
‘‘(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, if the application of this sec-
tion to such plan results in an increase for the 
plan year involved of the actual total costs of 
coverage with respect to medical and surgical 
benefits and mental health and substance-re-
lated disorder benefits under the plan (as deter-
mined and certified under subparagraph (C)) by 
an amount that exceeds the applicable percent-
age described in subparagraph (B) of the actual 
total plan costs, the provisions of this section 
shall not apply to such plan during the fol-
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lowing plan year, and such exemption shall 
apply to the plan for 1 plan year. 
‘‘(B) APPLICABLE PERCENTAGE.—With re-
spect to a plan, the applicable percentage de-
scribed 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 Men-
tal Health and Addiction Equity Act of 
2007; 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 for purposes of this subsection 
shall be made by a qualified actuary who is a 
member in good standing of the American 
Academy of Actuaries. Such determinations 
shall be certified by the actuary and be made 
available to the general public. 
‘‘(D) 6-MONTH
DETERMINATIONS.—If a 
group health plan seeks an exemption under 
this paragraph, determinations under subpara-
graph (A) shall be made after such plan has 
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complied with this section for the first 6 
months of the plan year involved.’’. 
(f) CHANGE IN EXCLUSION FOR SMALLEST EMPLOY-
ERS.—Subsection (c)(1) of such section is amended to 
read as follows: 
‘‘(1) SMALL EMPLOYER EXEMPTION.— 
‘‘(A) IN GENERAL.—This section shall not 
apply to any group health plan for any plan 
year of a small employer. 
‘‘(B) SMALL EMPLOYER.—For purposes of 
subparagraph (A), the term ‘small employer’ 
means, with respect to a calendar year and a 
plan year, an employer who employed an aver-
age of at least 2 (or 1 in the case of an em-
ployer residing in a State that permits small 
groups to include a single individual) but not 
more than 50 employees on business days dur-
ing the preceding calendar year. For purposes 
of the preceding sentence, all persons treated as 
a single employer under subsection (b), (c), 
(m), or (o) of section 414 shall be treated as 1 
employer and rules similar to rules of subpara-
graphs (B) and (C) of section 4980D(d)(2) 
shall apply.’’. 
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(g) ELIMINATION OF SUNSET PROVISION.—Such sec-
tion is amended by striking subsection (f). 
(h) CONFORMING AMENDMENTS TO HEADING.— 
(1) IN GENERAL.—The heading of such section 
is amended to read as follows: 
‘‘SEC. 9812. EQUITY IN MENTAL HEALTH AND SUBSTANCE- 
RELATED DISORDER BENEFITS.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for subchapter B of chapter 100 of the Inter-
nal Revenue Code of 1986 is amended by striking 
the item relating to section 9812 and inserting the 
following new item: 
‘‘Sec. 9812. Equity in mental health and substance-related disorder benefits.’’. 
(i) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2008. 
SEC. 5. GOVERNMENT ACCOUNTABILITY OFFICE STUDIES 
AND REPORTS. 
(a) IMPLEMENTATION OF ACT.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study that evaluates 
the effect of the implementation of the amendments 
made by this Act on— 
(A) the cost of health insurance coverage; 
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(B) access to health insurance coverage 
(including the availability of in-network pro-
viders); 
(C) the quality of health care; 
(D) Medicare, Medicaid, and State and 
local mental health and substance abuse treat-
ment spending; 
(E) the number of individuals with private 
insurance who received publicly funded health 
care for mental health and substance-related 
disorders; 
(F) spending on public services, such as 
the criminal justice system, special education, 
and income assistance programs; 
(G) the use of medical management of 
mental health and substance-related disorder 
benefits and medical necessity determinations 
by group health plans (and health insurance 
issuers offering health insurance coverage in 
connection with such plans) and timely access 
by participants and beneficiaries to clinically-in-
dicated care for mental health and substance- 
use disorders; and 
(H) other matters as determined appro-
priate by the Comptroller General. 
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(2) REPORT.—Not later than 2 years after the 
date of enactment of this Act, the Comptroller Gen-
eral shall prepare and submit to the appropriate 
committees of the Congress a report containing the 
results of the study conducted under paragraph (1). 
(b) BIANNUAL REPORT ON OBSTACLES IN OBTAIN-
ING COVERAGE.—Every two years, the Comptroller Gen-
eral shall submit to each House of the Congress a report 
on obstacles that individuals face in obtaining mental 
health and substance-related disorder care under their 
health plans. 
(c) UNIFORM PATIENT PLACEMENT CRITERIA.—Not 
later than 18 months after the date of the enactment of 
this Act, the Comptroller General shall submit to each 
House of the Congress a report on availability of uniform 
patient placement criteria for mental health and sub-
stance-related disorders that could be used by group 
health plans and health insurance issuers to guide deter-
minations of medical necessity and the extent to which 
health plans utilize such critiera. If such criteria do not 
exist, the report shall include recommendations on a proc-
ess for developing such criteria. 
Æ 
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