26 U.S.C. § 9812 : US Code - Section 9812: Parity in mental health and substance use disorder benefits

Search 26 U.S.C. § 9812 : US Code - Section 9812: Parity in mental health and substance use disorder benefits

    (a) In general
      (1) Aggregate lifetime limits
        In the case of a group health plan that provides both medical
      and surgical benefits and mental health or substance use disorder
      benefits - 
        (A) No lifetime limit
          If the plan does not include an aggregate lifetime limit on
        substantially all medical and surgical benefits, the plan may
        not impose any aggregate lifetime limit on mental health or
        substance use disorder benefits.
        (B) Lifetime limit
          If the plan includes an aggregate lifetime limit on
        substantially all medical and surgical benefits (in this
        paragraph referred to as the "applicable lifetime limit"), the
        plan shall either - 
            (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 application of such limit between such
          medical and surgical benefits and mental health and substance
          use disorder benefits; or
            (ii) not include any aggregate lifetime limit on mental
          health or substance use disorder benefits that is less than
          the applicable lifetime limit.
        (C) Rule in case of different limits
          In the case of a plan 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 with respect to mental
        health and substance use disorder benefits by substituting for
        the applicable lifetime limit an average aggregate lifetime
        limit that is computed 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 that provides both medical
      and surgical benefits and mental health or substance use disorder
      benefits - 
        (A) No annual limit
          If the plan does not include an annual limit on substantially
        all medical and surgical benefits, the plan may not impose any
        annual limit on mental health or substance use disorder
        benefits.
        (B) Annual limit
          If the plan includes an annual limit on substantially all
        medical and surgical benefits (in this paragraph referred to as
        the "applicable annual limit"), the plan 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 application of such limit between such
          medical 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 annual limit.
        (C) Rule in case of different limits
          In the case of a plan that is not described in subparagraph
        (A) or (B) and that includes no or different annual limits on
        different categories of medical and surgical benefits, the
        Secretary shall establish rules under which subparagraph (B) is
        applied to such plan with respect to mental health and
        substance use disorder benefits by substituting for the
        applicable annual limit an average annual limit that is
        computed taking into account the weighted average of the annual
        limits applicable to such categories.
      (3) Financial requirements and treatment limitations
        (A) In general
          In the case of a group health plan that provides both medical
        and surgical benefits and mental health or substance use
        disorder benefits, such plan shall ensure that - 
            (i) the financial requirements applicable to such mental
          health or substance use disorder benefits are no more
          restrictive than the predominant financial requirements
          applied to substantially all medical and surgical benefits
          covered by the plan, 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 applicable to such mental
          health or substance use disorder benefits are no more
          restrictive than the predominant treatment limitations
          applied to substantially all medical and surgical benefits
          covered by the plan and there are no separate treatment
          limitations that are applicable only with respect to mental
          health or substance use disorder benefits.
        (B) Definitions
          In this paragraph:
          (i) Financial requirement
            The term "financial requirement" includes deductibles,
          copayments, coinsurance, and out-of-pocket expenses, but
          excludes an aggregate lifetime limit and an annual limit
          subject to paragraphs (1) and (2),(!1)

          (ii) Predominant
            A financial requirement or treatment limit is considered to
          be predominant if it is the most common 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
          treatment.
      (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 shall be made available by the plan administrator in
      accordance with regulations to any current or potential
      participant, beneficiary, or contracting provider upon request.
      The reason for any denial under the plan of reimbursement or
      payment for services with respect to mental health or substance
      use disorder benefits in the case of any participant or
      beneficiary shall, on request or as otherwise required, be made
      available by the plan administrator to the participant or
      beneficiary in accordance with regulations.
      (5) Out-of-network providers
        In the case of a plan that provides both medical and surgical
      benefits and mental health or substance use disorder benefits, if
      the plan provides coverage for medical or surgical benefits
      provided by out-of-network providers, the plan shall provide
      coverage for mental health or substance use disorder benefits
      provided by out-of-network providers in a manner that is
      consistent with the requirements of this section.
    (b) Construction
      Nothing in this section shall be construed - 
        (1) as requiring a group health plan to provide any mental
      health or substance use disorder benefits; or
        (2) in the case of a group health plan that provides mental
      health or substance use disorder benefits, as affecting the terms
      and conditions of the plan relating to such benefits under the
      plan, except as provided in subsection (a).
    (c) Exemptions
      (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 average of at least 2 (or 1 in the
        case of an employer residing in a State that permits small
        groups to include a single individual) but not more than 50
        employees on business days during 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 subparagraphs (B) and (C) of section 4980D(d)(2) shall
        apply.
      (2) Cost exemption
        (A) In general
          With respect to a group health plan, if the application of
        this section 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 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 during the following plan year, and such
        exemption shall apply to the plan for 1 plan year. An employer
        may elect to continue to apply mental health and substance use
        disorder parity pursuant to this section with respect to the
        group health plan involved regardless of any increase in total
        costs.
        (B) Applicable percentage
          With respect to a plan, 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
        for purposes of this section shall be made and certified by a
        qualified and licensed actuary who is a member in good standing
        of the American Academy of Actuaries. All such determinations
        shall be in a written report prepared by the actuary. The
        report, and all underlying documentation relied upon by the
        actuary, shall be maintained by the group health plan for a
        period of 6 years following the notification made under
        subparagraph (E).
        (D) 6-month determinations
          If a group health plan seeks an exemption under this
        paragraph, determinations under subparagraph (A) shall be made
        after such plan has complied with this section for the first 6
        months of the plan year involved.
        (E) Notification
          (i) In general
            A group health plan that, based upon a certification
          described under subparagraph (C), qualifies for an exemption
          under this paragraph, and elects to implement the exemption,
          shall promptly notify the Secretary, the appropriate State
          agencies, and participants and beneficiaries in the plan of
          such election.
          (ii) Requirement
            A notification to the Secretary under clause (i) shall
          include - 
              (I) a description of the number of covered lives under
            the plan 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;
              (II) for both the plan year upon which a cost exemption
            is sought and the year prior, a description of the actual
            total costs of coverage with respect 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 mental health and substance use
            disorder benefits under the plan.
          (iii) Confidentiality
            A notification 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 includes - 
              (I) a breakdown of States by the size and type of
            employers submitting such notification; and
              (II) a summary of the data received under clause (ii).
        (F) Audits by appropriate agencies
          To determine compliance with this paragraph, the Secretary
        may audit the books and records of a group health plan relating
        to an exemption, including any actuarial reports prepared
        pursuant to subparagraph (C), during the 6 year period
        following 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 exemption
        covered by such notification.
    (d) Separate application to each option offered
      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 option.
    (e) Definitions
      For purposes of this section:
      (1) Aggregate lifetime limit
        The term "aggregate lifetime limit" means, with respect to
      benefits under a group health plan, a dollar limitation on the
      total amount that may be paid with respect to such benefits under
      the plan 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, 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 with respect 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 defined under the
      terms of the plan, 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 and in accordance with applicable Federal
      and State law.