Sec. 604. Enhanced compliance with mental health and substance use disorder coverage requirements
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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 1 year after the date of enactment of the Mental Health Reform 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.
The guidance issued under this paragraph shall include specific examples of methods that group health plans and health insurance issuers offering group or individual health insurance coverage may use for disclosing information to demonstrate compliance with the requirements under this section (and any regulations promulgated pursuant to this section), including methods for complying with requirements for nonquantitative treatment limitations. The guidance issued under this paragraph may include examples of standardized methods that group health plans and health insurance issuers offering group or individual health insurance coverage may use to provide any participant, beneficiary, or contracting provider, upon request, with documents containing coverage information that the health plans or issuers are required, by this section or any other provision of law, to disclose to such participants, beneficiaries, or contracting providers, including— information, including information that is comparative in nature, on nonquantitative treatment limitations for both medical and surgical benefits and mental health and substance use disorder benefits; information, including information that is comparative in nature, about the processes, strategies, evidentiary standards, and other factors used to apply nonquantitative treatment limitations for both medical and surgical benefits and mental health and substance use disorder benefits, including how such limitations are applied to mental health or substance use disorder benefits; and information, including information that is comparative in nature, about how nonquantitative treatment limitations are applied to medical and surgical benefits relative to how such limitations are applied to mental health or substance use disorder benefits.
The guidance issued under this paragraph shall include information that group health plans and health insurance issuers offering group or individual health insurance coverage may use to comply with requirements for nonquantitative treatment limitations under this section, including— examples of appropriate types of nonquantitative treatment limitations on mental health and substance use disorder benefits that comply or do not comply with this section, including— medical management standards that limit or exclude benefits based on medical necessity, medical 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 network admission standards and individual provider reimbursement rates, as such standards and rates apply to network adequacy, that comply or do not comply with this section; examples of sources of information that may serve as evidentiary standards for the purpose of determining compliance or noncompliance with applicable nonquantitative treatment limitation requirements; examples of specific factors that may be used by such plans or issuers in performing a nonquantitative treatment limitation analysis; examples of specific evidentiary standards that may be used by such plans or issuers to evaluate the specific factors described in clause (iv); examples of how a lack of clinical evidence may be taken into consideration by such plans or issuers in the case of experimental treatment exclusions; examples of how specific evidentiary standards may be applied to each service category or classification of benefits; examples of new mental health or substance use disorder treatments that comply or do not comply with this section, such as evidence-based early intervention programs for individuals with a serious mental illness and types of medical management techniques that have been determined to meet or fail to meet requirements for nonquantitative treatment limitations; examples of coverage determinations that comply or do not comply with this section and 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 involuntary commitment; examples of how nonquantitative treatment limitations and their application, determinations that treatments are no longer medically necessary, and efforts to terminate or reduce care may be resolved in a manner that is least burdensome to the patient and provides for continuity of patient care; and additional examples of coverage of mental health and substance use disorder benefits that comply or do not comply with this section, including cases in which restrictions based on geographic locations, facility type, provider specialty, or other criteria limit the scope or duration of benefits.
Prior to issuing any final guidance under this section, 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. . In the case of a group health plan or health insurance issuer offering health insurance coverage in the group or individual market with respect to which there are at least 5 findings of noncompliance with 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, the appropriate Secretary shall audit plan documents for such health plan or issuer in the following plan year 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.
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- 42 USC 300gg–26(a)
- 42 USC 300gg–26
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Sec. 604
Enhanced compliance with mental health and substance use disorder coverage requirements
Cite42 USC 300gg–26(a)
Cite42 USC 300gg–26
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