Sec. 801. Enhanced compliance with mental health and substance use disorder coverage requirements
1,985 words·~9 min read·
/bill/114/hr/2646/rds/section-801A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Section 2726(a) of the Public Health Service Act ( 42 U.S.C. 300gg–26(a) ) is amended by adding at the end the following: Not later than 12 months after the date of enactment of the Helping Families in Mental Health Crisis 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, 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.
The compliance program guidance document required under this paragraph shall provide 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 section, section 712 of the Employee Retirement Income Security Act of 1974, or section 9812 of the Internal Revenue Code of 1986, as applicable, based on investigations of violations of such sections, including— examples illustrating requirements for information disclosures and nonquantitative treatment limitations; and descriptions of the violations uncovered during the course of such investigations.
To the extent that any example described in clause
(i)involves a finding of compliance or noncompliance with regard to any requirement for nonquantitative treatment limitations, the example shall provide sufficient detail to fully explain such finding, including a full description of the criteria involved for medical and surgical benefits and the criteria involved for mental health and substance use disorder benefits. In developing and issuing the compliance program guidance document required under this paragraph, the Secretaries specified in subparagraph (A)— shall enter into interagency agreements 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 to share findings 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 shall seek to enter into an agreement with a State to share information on findings 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. The compliance program guidance document shall include recommendations to comply 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 encourage the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements. Such internal controls may include a compliance checklist with illustrative examples of nonquantitative treatment limitations on mental health and substance use disorder benefits, which may fail to comply 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, in relation to nonquantitative treatment limitations on medical and surgical benefits. The compliance program guidance document shall be updated 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 section, section 712 of the Employee Retirement Income Security Act of 1974, or section 9812 of the Internal Revenue Code of 1986, as applicable. . Section 2726(a) of the Public Health Service Act ( 42 U.S.C. 300gg–26(a) ), as amended by subsection (a), is further amended by adding at the end the following: Not later than 1 year after the date of enactment of the Helping Families in Mental Health Crisis Act of 2016 , the Secretary, in coordination with the Secretary of Labor and the Secretary 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 satisfying the requirements of 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,. The guidance issued under this paragraph shall include clarifying information and illustrative examples of methods that group health plans and health insurance issuers offering group or individual health insurance coverage may use for disclosing 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). The guidance issued under this paragraph shall include clarifying information and illustrative examples of methods that group health plans and health insurance issuers offering group or individual health insurance coverage may use to provide any participant, beneficiary, contracting provider, or authorized representative, as applicable, with documents containing information that the health plans or issuers are required to disclose to participants, beneficiaries, contracting providers, or authorized representatives to ensure compliance 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; any regulation issued pursuant to such respective section, or any other applicable law or regulation, including information that is comparative in nature with respect to— nonquantitative treatment limitations for both medical and surgical benefits and mental health and substance use disorder benefits; the processes, strategies, evidentiary standards, and other factors used to apply the limitations described in subclause (I); and the application of the limitations described in subclause
(I)to ensure that such limitations are applied in parity with respect to both medical and surgical benefits and mental health and substance use disorder benefits. The guidance issued under this paragraph shall include clarifying information and illustrative examples of methods, processes, strategies, evidentiary standards, and other factors that group health plans and health insurance issuers offering group or individual health insurance coverage may use regarding the development and application of nonquantitative treatment limitations to ensure compliance 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 any regulations promulgated pursuant to such respective section), including— examples of methods of determining appropriate types of nonquantitative treatment limitations with respect to both medical and surgical benefits and mental health and substance use disorder benefits, including nonquantitative treatment limitations pertaining to— medical management standards based on medical necessity or appropriateness, or whether a treatment is experimental or investigative; limitations with respect to prescription drug formulary design; and use of fail-first or step therapy protocols; examples of methods of determining— network admission standards (such as credentialing); and factors used in provider reimbursement methodologies (such as service type, geographic market, demand for services, and provider supply, practice size, training, experience, and licensure) as such factors apply to network adequacy; examples of sources of information that may serve as evidentiary standards for the purposes of making determinations regarding the development and application of nonquantitative treatment limitations; 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; examples of how specific evidentiary standards may be used to determine whether treatments are considered experimental or investigative; examples of how specific evidentiary standards may be applied to each service category or classification of benefits; examples of methods of reaching appropriate coverage determinations for new mental health or substance use disorder treatments, such as evidence-based early intervention programs for individuals with a serious mental illness and types of medical management techniques; examples of methods of reaching appropriate coverage determinations for which there is an indirect relationship between the covered mental health or substance use disorder benefit and a traditional covered medical and surgical benefit, such as residential treatment or hospitalizations involving voluntary or involuntary commitment; and additional illustrative examples of methods, processes, strategies, evidentiary standards, and other factors for which the Secretary determines that additional 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 Internal Revenue Code of 1986, as applicable. 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. . Paragraph
(4)of section 2726(a) of the Public Health Service Act ( 42 U.S.C. 300gg–26(a) ) is amended to read as follows: The criteria for medical necessity determinations made under the plan or health insurance coverage with respect to mental health or substance use disorder benefits or medical or surgical benefits, the reason for denial of any such benefits, and any other information appropriate to demonstrate compliance under this section (including any such medical and surgical information) shall be made available by the plan administrator (or the health insurance issuer offering such coverage) in accordance with applicable regulations to the current or potential participant, beneficiary, or contracting provider involved upon request. The Secretary may promulgate any such regulations, including interim final regulations or temporary regulations, as may be appropriate to carry out this paragraph. . Paragraph
(4)of section 712(a) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185a(a) ) is amended to read as follows: The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits or medical or surgical benefits (or the health insurance coverage offered in connection with the plan with respect to such benefits), the reason for denial of any such benefits, and any other information appropriate to demonstrate compliance under this section (including any such medical and surgical information) shall be made available by the plan administrator (or the health insurance issuer offering such coverage) in accordance with applicable regulations to the current or potential participant, beneficiary, or contracting provider involved upon request. The Secretary may promulgate any such regulations, including interim final regulations or temporary regulations, as may be appropriate to carry out this paragraph. . Paragraph
(4)of section 9812(a) of the Internal Revenue Code of 1986 is amended to read as follows: The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits or medical or surgical benefits, the reason for denial of any such benefits, and any other information appropriate to demonstrate compliance under this section (including any such medical and surgical information) shall be made available by the plan administrator in accordance with applicable regulations to the current or potential participant, beneficiary, or contracting provider involved upon request. The Secretary may promulgate any such regulations, including interim final regulations or temporary regulations, as may be appropriate to carry out this paragraph. . In the case that the Secretary of Health and Human Services, the Secretary of Labor, or the Secretary of the Treasury determines that a group health plan or health insurance issuer offering group or individual health insurance coverage has violated, at least five times, section 2726 of the Public Health Service Act ( 42 U.S.C. 300gg–26 ), section 712 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185a ), or section 9812 of the Internal Revenue Code of 1986, respectively, the appropriate Secretary shall audit plan documents for such health plan or issuer in the plan year following the Secretary’s determination in order to help improve compliance with such section. Nothing in this subsection shall be construed to limit the authority, as in effect on the day before the date of enactment of this Act, of the Secretary of Health and Human Services, the Secretary of Labor, or the Secretary of the Treasury to audit documents of health plans or health insurance issuers.
Connectionstraces to 1
Traces to 1 document
2 references not yet in our index
- 42 USC 300gg–26(a)
- 42 USC 300gg–26
Citation graph
cites case law
Sec. 801
Enhanced compliance with mental health and substance use disorder coverage requirements
Cite42 USC 300gg–26(a)
Cite42 USC 300gg–26
Cites 3Cited by 0 across 0 sources