,,ii #aadth ,,congress #b;d ,session ,s4 #bfdg ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #g1 #bjaf ,ms4 ,warren 7for herself1 ,mr4 ,brown1 ,mr4 ,franken1 ,mr4 ,blumenthal1 and ,ms4 ,baldwin7 introduced the following bill2 which was read twice and referred to the ,committee on ,health1 ,education1 ,labor1 and ,pensions ,a ,,bill ,to strengthen parity in mental health and substance use disorder benefits4 #a4 ,short title ,this ,act may be cited as the ,behavioral ,health ,coverage ,transparency ,act of #bjaf4 #b4 ,strengthening parity in mental health and substance use disorder benefits 7a7 ,public ,health ,service ,act ,section #bgbf of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#bf7 is amended-- 7#a7 in subsection 7a71 by adding at the end the following3 7#f7 ,disclosure and enforcement requirements 7,a7 ,disclosure requirements 7i7 ,regulations ,not later than ,september #cj1 #bjaf1 the ,secretary1 in cooperation with the ,secretaries of ,labor and the ,treasury1 as appropriate1 shall issue additional regulations for carrying out this section1 including an explanation of documents that must be disclosed by group health plans or health insurance issuers offering group or individual health insurance coverage1 the process governing the disclosure of such documents1 and analyses that must be conducted by such plans and issuers to comply with this section4 7ii7 ,requirements ,a group health plan or a health insurance issuer offering group or individual health insurance coverage shall disclose to the ,secretary in a standardized format documents that include-- 7,i7 the specific analyses performed to ensure compliance with this section and any regulations promulgated pursuant to this section2 7,,ii7 a description of the application of non-quantitative treatment limitations 7in this paragraph referred to as ,n,q,t,ls7 to benefits offered by such plan or issuer1 including-- 7aa7 the specific factors the plan or issuer used in performing its ,n,q,t,ls analysis2 7bb7 the specific evidentiary standards relied on to evaluate such factors2 7cc7 how the evidentiary standards are applied to each service category for mental health1 substance use disorders1 medical benefits1 and surgical benefits2 7dd7 a disclosure of the results of the analyses of the specific evidentiary standards in each service category2 and 7ee7 a disclosure of the specific findings of such plan or issuer in each service category and the conclusions reached with respect to whether the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls with respect to medical and surgical benefits in the same classification2 and 7,,iii7 the rates of and reasons for denial by the plan or issuer for outpatient and inpatient mental health and substance use disorder services compared to the rates of and reasons for denial of claims for medical and surgical services4 7iii7 ,guidance ,the ,secretary1 in cooperation with the ,secretaries of ,labor and the ,treasury1 as appropriate1 shall issue guidance to group health plans or health insurance issuers offering group or individual health insurance coverage on how to satisfy the requirements of this section with respect to making information available to current and potential participants and beneficiaries4 ,such information shall include certificate of coverage documents and instruments under which the plan or coverage involved is administered and operated that specify1 include1 or refer to procedures1 formulas1 and methodologies applied to determine a participant or beneficiary's benefit under the plan or coverage1 regardless of whether such information is contained in a document designated as the plan document4 ,such guidance shall include a disclosure of how the plan or coverage involved has demonstrated that processes1 strategies1 evidentiary standards1 and other factors used in applying ,n,q,t,ls to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls with respect to medical and surgical benefits in the same classification4 7iv7 ,definitions ,in this paragraph1 the terms non-quantitative treatment limitations1 comparable to1 and applied no more stringently than have the meanings given such terms in parts #adf and #adg of title #de1 ,code of ,federal ,regulations 7or any successor regulation74 7,b7 ,enforcement 7i7 ,process for complaints ,the ,secretary1 in cooperation with the ,secretaries of ,labor and the ,treasury1 as appropriate1 shall issue guidance to clarify the process and timeline for current and potential participants and beneficiaries 7and authorized representatives and health care providers of such participants and beneficiaries7 of group health plans or health insurance issuers offering group or individual health insurance coverage to file formal complaints of such plans or issuers being in violation of this section1 including guidance1 by plan type1 on the relevant ,state1 regional1 and national offices1 including the consumer parity unit established under paragraph 7#g71 with which such complaints should be filed4 7ii7 ,authority for public enforcement ,the ,secretary1 in consultation with the ,secretaries of ,labor and the ,treasury1 shall make available to the public on the website of the consumer parity unit established under paragraph 7#g7 information on audits and investigations of group health plans and health insurance issuers conducted under this section4 ,such information shall not contain any personally identifiable information4 7iii7 ,audits 7,i7 ,randomized audits ,the ,secretary1 in cooperation with the ,secretaries of ,labor and the ,treasury1 may conduct randomized audits of group health plans or health insurance issuers offering group or individual health insurance coverage to determine compliance with this section4 ,such audits shall be conducted on not fewer than #ab plans and issuers per plan year4 ,information from such audits shall be made plainly available on the website of the consumer parity unit established under paragraph 7#g74 7,,ii7 ,additional audits ,in the case of a group health plan or health insurance issuer offering group or individual health insurance coverage with respect to which any claim has been filed during a plan year1 the ,secretary may audit the books and records of such plan or issuer to determine compliance with this section4 ,information detailing the results of the audit shall be made available on the website of the consumer parity unit established under paragraph 7#g74 7#g7 ,consumer parity unit 7,a7 ,in general ,the ,secretary1 in cooperation with the ,secretaries of ,labor and the ,treasury1 shall establish a consumer parity unit 7referred to in this paragraph as the unit7 with functions that include-- 7i7 developing and administering a single1 toll-free telephone number1 an ,internet website1 and a database1 or using an existing database1 to facilitate the centralized collection of1 monitoring of1 and response to consumer complaints or inquiries regarding violations of this section1 section #gab of the ,employee ,retirement ,income ,security ,act of #aigd or section #ihab7;a77#f7 of the ,internal ,revenue ,code of #aihf2 and 7ii7 providing information to health care consumers that is submitted to the ,secretary1 the ,secretary of ,labor1 and the ,secretary of the ,treasury under paragraph 7#f71 section #gab7;a77#f7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;a7a77#f771 or section #ihab7;a77#f7 of the ,internal ,revenue ,code of #aihf1 respectively4 7,b7 ,response to consumer complaints and inquiries 7i7 ,timely response to consumers ,the ,secretary of ,health and ,human ,services1 in cooperation with the ,secretaries of ,labor and the ,treasury1 shall establish reasonable procedures to provide a timely response 7in writing if appropriate7 to consumers regarding complaints received by the unit against1 or inquiries concerning1 a group health plan or health insurance issuer offering group or individual health insurance coverage1 including-- 7,i7 steps that have been taken by the appropriate ,state or ,federal enforcement agency in response to the complaint or inquiry of the consumer2 7,,ii7 any responses received by the appropriate ,state or ,federal enforcement agency from the group health plan or health insurance issuer offering group or individual health insurance coverage2 7,,iii7 any follow-up actions or planned follow-up actions by the appropriate regulator in response to the complaint or inquiry of the consumer2 and 7,,iv7 contact information of the appropriate enforcement agency for the consumer to follow up on the complaint or inquiry4 7ii7 ,timely response to regulators ,a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide a timely response 7in writing if appropriate7 to the appropriate ,state or ,federal enforcement agency having jurisdiction over such plan or issuer concerning a consumer complaint or inquiry submitted to the unit including-- 7,i7 steps that have been taken by the plan or issuer to respond to the complaint or inquiry of the consumer2 7,,ii7 any responses received by the plan or issuer from the consumer2 and 7,,iii7 follow-up actions or planned follow-up actions by the plan or issuer in response to the complaint or inquiry of the consumer4 2 and 7#b7 by adding at the end the following3 7f7 ,annual reports 7#a7 ,provision of information by ,states ,not later than ,december #ca1 #bjag1 and annually thereafter1 each ,state health insurance commissioner shall submit to the ,secretary a report on compliance with this section of group health plans or health insurance issuers offering group or individual health insurance coverage in such ,state4 7#b7 ,requirement of comparison ,to ensure that group health plans or health insurance issuers offering group or individual health insurance coverage provide comparable coverage for mental health and substance use disorder benefits in accordance with this section1 as part of the report submitted under paragraph 7#a71 a ,state health insurance commissioner shall compare the financial requirements and treatment limitations imposed by such issuers and plans for mental health and substance use disorder services and those requirements and limitations imposed by such issuers and plans on medical and surgical benefits4 7#c7 ,contents of reports ,the reports submitted under paragraph 7#a7 shall be made publicly available on the website of the consumer parity unit established under subsection 7a77#g7 and include the following information1 broken down for each group health plan or health insurance issuer offering group or individual health insurance coverage3 7,a7 ,the mental health and substance use disorder benefits provided by the plan or issuer4 7,b7 ,new mental health or substance use disorder treatments that have been approved for coverage4 7,c7 ,standards for admission to plan provider networks1 including reimbursement rates1 and an accurate1 up-to-date provider network listing1 including information on which providers are accepting new patients4 7,d7 ,non-quantitative treatment limitations on coverage1 including-- 7i7 medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness1 or based on whether a treatment is experimental or investigative2 7ii7 formulary design for prescription drugs2 7iii7 plan methods used to determine usual1 customary1 and reasonable fee charges2 7iv7 refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective 7also known as fail-first policies or step therapy protocols72 7v7 exclusions based on failure to complete a course of treatment2 and 7vi7 restrictions based on geographic location1 facility type1 provider specialty1 and other criteria that might otherwise limit the scope or duration of benefits4 7,e7 ,information needed to calculate out-of-pocket costs4 4 7b7 ,employee ,retirement ,income ,security ,act of #aigd ,section #gab7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;a7a77 is amended by adding at the end the following3 7#f7 ,disclosure and enforcement requirements 7,a7 ,disclosure requirements 7i7 ,regulations ,not later than ,june #cj1 #bjaf1 the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and the ,treasury1 as appropriate1 shall issue additional regulations for carrying out this section1 including an explanation of documents that must be disclosed by group health plans 7or health insurance coverage offered in connection with such plans71 the process governing the disclosure of such documents1 and analyses that must be conducted by such plans or coverage to comply with this section4 7ii7 ,requirements ,a group health plan 7or health insurance coverage offered in connection with such a plan7 shall disclose to the ,secretary in a standardized format documents that include-- 7,i7 the specific analyses performed to ensure compliance with this section and any regulations promulgated pursuant to this section2 7,,ii7 a description of the application of non-quantitative treatment limitations 7in this paragraph referred to as ,n,q,t,ls7 to benefits under such plan or coverage1 including-- 7aa7 the specific factors the plan or coverage used in performing its ,n,q,t,ls analysis2 7bb7 the specific evidentiary standards relied on to evaluate such factors2 7cc7 how the evidentiary standards are applied to each service category for mental health1 substance use disorders1 medical benefits1 and surgical benefits2 7dd7 a disclosure of the results of the analyses of the specific evidentiary standards in each service category2 and 7ee7 a disclosure of the specific findings of such plan or coverage in each service category and the conclusions reached with respect to whether the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls with respect to medical and surgical benefits in the same classification2 and 7,,iii7 the rates of and reasons for denial by the plan or coverage for outpatient and inpatient mental health and substance use disorder services compared to the rates of and reasons for denial of claims for medical and surgical services4 7iii7 ,guidance ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and the ,treasury1 as appropriate1 shall issue guidance to group health plans 7and health insurance coverage offered in connection with such plans7 on how to satisfy the requirements of this section with respect to making information available to current and potential participants and beneficiaries4 ,such information shall include certificate of coverage documents and instruments under which the plan or coverage involved is administered and operated that specify1 include1 or refer to procedures1 formulas1 and methodologies applied to determine a participant or beneficiary's benefit under the plan or coverage1 regardless of whether such information is contained in a document designated as the plan document4 ,such guidance shall include a disclosure of how the plan or coverage involved has provided that processes1 strategies1 evidentiary standards1 and other factors used in applying the ,,nqtl to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying the limitation with respect to medical and surgical benefits in the same classification4 7iv7 ,definitions ,in this paragraph1 the terms non-quantitative treatment limitations1 comparable to1 and applied no more stringently than have the meanings given such terms in parts #adf and #adg of title #de1 ,code of ,federal ,regulations 7or any successor regulation74 7,b7 ,enforcement 7i7 ,process for complaints ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and the ,treasury1 as appropriate1 shall issue guidance to clarify the process and timeline for current and potential participants and beneficiaries 7and authorized representatives and health care providers of such participants and beneficiaries7 of group health plans 7or health insurance coverage offered in connection with such a plan7 to file formal complaints of such plans or coverage being in violation of this section1 including guidance1 by plan type1 on the relevant ,state1 regional1 and national offices with which such complaints should be filed4 7ii7 ,authority for public enforcement ,the ,secretary1 in consultation with the ,secretaries of ,labor and the ,treasury1 shall make available to the public on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act information on audits and investigations of group health plans 7and health insurance coverage offered in connection with such plans7 conducted under this section4 ,such information shall not contain any personally identifiable information4 7iii7 ,audits 7,i7 ,randomized audits ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and the ,treasury1 may conduct randomized audits of group health plans 7and health insurance coverage offered in connection with such plans7 to determine compliance with this section4 ,such audits shall be conducted on not fewer than #ab plans and coverages per plan year4 ,information from such audits shall be made plainly available on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act4 7,,ii7 ,additional audits ,in the case of a group health plan 7and health insurance coverage offered in connection with such a plan7 with respect to which any claim has been filed during a plan year1 the ,secretary may audit the books and records of such plan or coverage to determine compliance with this section4 ,information detailing the results of the audit shall be made available on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act4 4 7c7 ,internal ,revenue ,code of #aihf ,section #ihab7;a7 of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 7#f7 ,disclosure and enforcement requirements 7,a7 ,disclosure requirements 7i7 ,regulations ,not later than ,june #cj1 #bjaf1 the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and ,labor1 as appropriate1 shall issue additional regulations for carrying out this section1 including an explanation of documents that must be disclosed by group health plans1 the process governing the disclosure of such documents1 and analyses that must be conducted by such plans to comply with this section4 7ii7 ,requirements ,a group health plan shall disclose to the ,secretary in a standardized format documents that include-- 7,i7 the specific analyses performed to ensure compliance with this section and any regulations promulgated pursuant to this section2 7,,ii7 a description of the application of non-quantitative treatment limitations 7in this paragraph referred to as ,n,q,t,ls7 to benefits under such group health plan1 including-- 7aa7 the specific factors the plan used in performing its ,n,q,t,ls analysis2 7bb7 the specific evidentiary standards relied on to evaluate such factors2 7cc7 how the evidentiary standards are applied to each service category for mental health1 substance use disorders1 medical benefits1 and surgical benefits2 7dd7 a disclosure of the results of the analyses of the specific evidentiary standards in each service category2 and 7ee7 a disclosure of the specific findings of such plan in each service category and the conclusions reached with respect to whether the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls with respect to medical and surgical benefits in the same classification2 and 7,,iii7 the rates of and reasons for denial by the plan for outpatient and inpatient mental health and substance use disorder services compared to the rates of and reasons for denial of claims for medical and surgical services4 7iii7 ,guidance ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and ,labor1 as appropriate1 shall issue guidance to group health plans on how to satisfy the requirements of this section with respect to making information available to current and potential participants and beneficiaries4 ,such information shall include certificate of coverage documents and instruments under which the plan involved is administered and operated that specify1 include1 or refer to procedures1 formulas1 and methodologies applied to determine a participant or beneficiary's benefit under the plan1 regardless of whether such information is contained in a document designated as the plan document4 ,such guidance shall include a disclosure of how the plan involved has demonstrated that processes1 strategies1 evidentiary standards1 and other factors used in applying ,n,q,t,ls to mental health or substance use disorder benefits are comparable to1 and applied no more stringently than1 the processes1 strategies1 evidentiary standards1 or other factors used in applying ,n,q,t,ls with respect to medical and surgical benefits in the same classification4 7iv7 ,definitions ,in this paragraph1 the terms non-quantitative treatment limitations1 comparable to1 and applied no more stringently than have the meanings given such terms in parts #adf and #adg of title #de1 ,code of ,federal ,regulations 7or any successor regulation74 7,b7 ,enforcement 7i7 ,process for complaints ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and ,labor1 as appropriate1 shall1 with respect to group health plans1 issue guidance to clarify the process and timeline for current and potential participants and beneficiaries 7and authorized representatives and health care providers of such participants and beneficiaries7 with respect to such plans to file formal complaints of such plans being in violation of this section1 including guidance1 by plan type1 on the relevant ,state1 regional1 and national offices with which such complaints should be filed4 7ii7 ,authority for public enforcement ,the ,secretary1 in consultation with the ,secretaries of ,labor and the ,treasury1 shall make available to the public on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act information on audits and investigations of group health plans conducted under this section4 ,such information shall not contain any personally identifiable information4 7iii7 ,audits 7,i7 ,randomized audits ,the ,secretary1 in cooperation with the ,secretaries of ,health and ,human ,services and ,labor1 is authorized to conduct randomized audits of group health plans to determine compliance with this section4 ,such audits shall be conducted on not fewer than #ab plans per plan year4 ,information from such audits shall be made plainly available on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act4 7,,ii7 ,additional audits ,in the case of a group health plan with respect to which any claim has been filed during a plan year1 the ,secretary may audit the books and records of such plan to determine compliance with this section4 ,information detailing the results of the audit shall be made available on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act4 4 7d7 ,,gao ,study on ,mental ,health and ,substance ,use ,parity ,enforcement ,efforts ,not later than #a year after the date of enactment of this ,act1 the ,comptroller ,general of the ,united ,states1 in consultation with the ,secretary of ,health and ,human ,services1 the ,secretary of ,labor1 and the ,secretary of the ,treasury1 shall submit to ,congress1 and make plainly available on the website of the consumer parity unit established under section #bgbf7;a77#g7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#bf7;a77#g771 as added by subsection 7a71 a report detailing the enforcement efforts of the responsible departments and agencies in implementing sections #bgbf of the ,public ,health ,service ,act1 #gab of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;a71 and #ihab of the ,internal ,revenue ,code of #aihf1 including-- 7#a7 the number of investigations and audits that have been conducted into potential parity violations2 7#b7 the number of enforcement actions carried out as a result of any such investigation or audit2 and 7#c7 details on any such investigation1 audit1 or enforcement action that do not contain any personally identifiable information4 7e7 ,authorization of appropriations ,there is authorized to be appropriated #b1jjj1jjj for each of fiscal years #bjaf through #bjbj to carry out this section1 including the amendments made by this section4