Sec. 5. State and Tribal ombudsman programs relating to mental health and substance use disorder parity

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Part C of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–91 et seq. ) is amended— by redesignating section 2794 ( 42 U.S.C. 300gg–95 ) (regarding uniform fraud and abuse referral format), as added by section 6603 of the Patient Protection and Affordable Care Act ( Public Law 111–148 ), as section 2795; and by adding at the end the following: The Secretary shall make grants to eligible entities, designated by a State, Indian Tribe, or Tribal organization, as described in subsection (b), for the purpose of— establishing or supporting State and Tribal mental health and substance use disorder parity ombudsman programs to— educate consumers about the mental health and substance use disorder coverage in individual plans, group health plans, self-insured plans, and State Medicaid managed care plans; assist consumers in understanding their rights as health benefits plan members, including appeal processes and how to use such benefits, and how to access appropriate medical information; assist consumers in exercising their rights under the provisions of part D, including resolving problems related to a group health plan or health insurance issuer erroneously charging a consumer out-of-network rates for services listed in-network on the group health plan or health insurance issuer’s provider directory; identify, investigate, and help resolve complaints related to mental health and substance use disorder coverage (including potential violations of the mental health and substance use disorder parity laws) on behalf of consumers; maintain a toll-free hotline and website for consumers; collect, track, and quantify problems and inquiries encountered by consumers; and other activities as defined by the Secretary; and provide support and training for such State and Tribal mental health parity ombudsman programs (such as through the establishment of a mental health parity ombudsman program resource center).

To be eligible to receive a grant under this section, a State, Indian Tribe, or Tribal organization shall designate an ombudsman or consumer assistance program or other independent entity that— has specialized knowledge of mental health conditions and substance use disorders and experience resolving inquiries and complaints; and directly, or in coordination with departments of insurance, and consumer assistance organizations, receives and responds to inquiries and complaints concerning access to mental health and substance use disorder services.

A State, Indian Tribe, or Tribal organization that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant. As a condition of receiving a grant, an eligible entity shall agree to— collect and report data to the Secretary, State legislature, and relevant State agencies, including the departments of insurance and the State attorney general, on the numbers and types of problems and inquiries encountered by individuals with respect to access to behavioral health services; and report to the Secretary on how identified problems were addressed, including through promising practices related to responding to mental health and substance use disorder coverage issues, including appeals and education.

Not later than 4 years after the date of the enactment of the Behavioral Health Network and Directory Improvement Act , the Secretary shall submit to Congress a report on the data collected under subsection. In this section, the terms Indian Tribe and Tribal organization have the meanings given such terms in section 4 of the Indian Self-Determination and Education Assistance Act. To carry out this section, there are authorized to be appropriated $20,000,000 for fiscal year 2024 and $10,000,000 for fiscal year 2025 and each fiscal year thereafter. .

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42 USC 300gg–91
42 USC 300gg–95
Pub. L. 111-148

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Sec. 5

State and Tribal ombudsman programs relating to mental health and substance use disorder parity

Cite42 USC 300gg–91

Cite42 USC 300gg–95

Pub. L.Pub. L. 111-148

Cites 3Cited by 0 across 0 sources