,,ib ,union ,calendar ,no4 #ege #aafth  
,,congress  #b;d ,session  ,h4 ,r4 #geci
 ,report ,no4 #aaf-fib1 ,part ,i ,,in   
,,the ,,house ,,of ,,representatives    
,july #i1 #bjbj,mr4 ,kennedy 7for       
himself1 ,ms4 ,porter1 ,mr4 ,bilirakis1 
and ,mr4 ,upton7 introduced the         
following bill2 which was referred to   
the ,committee on ,energy and ,commerce1
 and in addition to the ,committees on  
,ways and ,means1 and ,education and    
,labor1 for a period to be subsequently 
determined by the ,speaker1 in each case
 for consideration of such provisions as
 fall within the jurisdiction of the    
committee concerned  ,december #bd1     
#bjbj;,additional sponsors3 ,mr4 ,lujn1 
,mr4 ,soto1 and ,mr4 ,fitzpatrick       
,december #bd1 #bjbj,reported from the  
,committee on ,energy and ,commerce with
 an amendment,strike out all after the  
enacting clause and insert the part     
printed in italic  ,december #bd1       
#bjbj;,committees on ,ways and ,means   
and ,education and ,labor discharged2   

committed to the ,committee of the      
,whole ,house on the ,state of the      
,union and ordered to be printed,for    
text of introduced bill1 see copy of    
bill as introduced on ,july #i1 #bjbj   
,a ,,bill  ,to strengthen parity in     
mental health and substance use disorder
 benefits4  #a4 ,short title ,this ,act 
may be cited as the ,strengthening      
,behavioral ,health ,parity ,act4  #b4  
,strengthening parity in mental health  
and substance use disorder benefits  7a7
 ,,phsa  7#a7 ,in general ,title ,,xxvii
 of the ,public ,health ,service ,act   
7#db ,u4,s4,c4 #cjj;gg-#aa et seq47 is  
amended by adding at the end the        
following new part3  ,d ,additional     
,coverage ,provisions  #bgii;,a-#a4     
,parity in mental health and substance  
use disorder benefits  7a7 ,in ,general 
7#a7 ,aggregate lifetime limits ,in the 
case of a group health plan or a health 
insurance issuer offering group or      
individual health insurance coverage    
that provides both medical and surgical 

benefits and mental health or substance 
use disorder benefits-- 7,a7 ,no        
lifetime limit ,if the plan or coverage 
does not include an aggregate lifetime  
limit on substantially all medical and  
surgical benefits1 the plan or coverage 
may not impose any aggregate lifetime   
limit on mental health or substance use 
disorder benefits4  7,b7 ,lifetime limit
 ,if the plan or coverage includes an   
aggregate lifetime limit on             
substantially all medical and surgical  
benefits 7in this paragraph referred to 
as the applicable lifetime limit71 the  
plan or coverage shall either-- 7i7     
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      
benefits2 or  7ii7 not include any      
aggregate lifetime limit on mental      

health or substance use disorder        
benefits that is less than the          
applicable lifetime limit4  7,c7 ,rule  
in case of different limits ,in the case
 of a plan or coverage that is not      
described in subparagraph 7,a7 or 7,b7  
and that includes no or different       
aggregate lifetime limits on different  
categories of medical and surgical      
benefits1 the ,secretary shall establish
 rules under which subparagraph 7,b7 is 
applied to such plan or coverage 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      
categories4  7#b7 ,annual limits ,in the
 case of a group health plan or a health
 insurance issuer offering group or     
individual health insurance coverage    
that provides both medical and surgical 
benefits and mental health or substance 

use disorder benefits-- 7,a7 ,no annual 
limit ,if the plan or coverage does not 
include an annual limit on substantially
 all medical and surgical benefits1 the 
plan or coverage may not impose any     
annual limit on mental health or        
substance use disorder benefits4  7,b7  
,annual limit ,if the plan or coverage  
includes an annual limit on             
substantially all medical and surgical  
benefits 7in this paragraph referred to 
as the applicable annual limit71 the    
plan or coverage shall either-- 7i7     
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      
benefits2 or  7ii7 not include any      
annual limit on mental health or        
substance use disorder benefits that is 
less than the applicable annual limit4  

7,c7 ,rule in case of different limits  
,in the case of a plan or coverage that 
is not described in subparagraph 7,a7 or
 7,b7 and that includes no or different 
annual limits on different categories of
 medical and surgical benefits1 the     
,secretary shall establish rules under  
which subparagraph 7,b7 is applied to   
such plan or coverage 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       
categories4  7#c7 ,financial            
requirements and treatment limitations  
7,a7 ,in general ,in the case of a group
 health plan or a health insurance      
issuer offering group or individual     
health insurance coverage that provides 
both medical and surgical benefits and  
mental health or substance use disorder 
benefits1 such plan or coverage shall   
ensure that-- 7i7 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  
7or coverage71 and there are no separate
 cost sharing requirements that are     
applicable only with respect to mental  
health or substance use disorder        
benefits2 and  7ii7 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  
7or coverage7 and there are no separate 
treatment limitations that are          
applicable only with respect to mental  
health or substance use disorder        
benefits4  7,b7 ,definitions ,in this   
paragraph3 7i7 ,financial requirement   
,the term financial requirement includes
 deductibles1 copayments1 coinsurance1  

and out-of-pocket expenses1 but excludes
 an aggregate lifetime limit and an     
annual limit subject to paragraphs 7#a7 
and 7#b74  7ii7 ,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 requirement4  7iii7    
,treatment limitation ,the term         
treatment limitation includes limits on 
the frequency of treatment1 number of   
visits1 days of coverage1 or other      
similar limits on the scope or duration 
of treatment4  7#d7 ,availability of    
plan information ,the criteria for      
medical necessity determinations made   
under the plan with respect to mental   
health or substance use disorder        
benefits 7or the health insurance       
coverage offered in connection with the 
plan with respect to such benefits7     
shall be made available by the plan     
administrator 7or the health insurance  
issuer offering such coverage7 in       
accordance with regulations to any      

current or potential participant1       
beneficiary1 or contracting provider    
upon request4 ,the reason for any denial
 under the plan 7or coverage7 of        
reimbursement or payment for services   
with respect to mental health or        
substance use disorder benefits in the  
case of any participant or beneficiary  
shall1 on request or as otherwise       
required1 be made available by the plan 
administrator 7or the health insurance  
issuer offering such coverage7 to the   
participant or beneficiary in accordance
 with regulations4  7#e7 ,out-of-network
 providers ,in the case of a plan or    
coverage that provides both medical and 
surgical benefits and mental health or  
substance use disorder benefits1 if the 
plan or coverage provides coverage for  
medical or surgical benefits provided by
 out-of-network providers1 the plan or  
coverage 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 section4 
7#f7 ,compliance program guidance       
document  7,a7 ,in general ,not later   
than #ab months after the date of       
enactment of the ,helping ,families in  
,mental ,health ,crisis ,reform ,act of 
#bjaf1 the ,secretary1 the ,secretary of
 ,labor1 and the ,secretary of the      
,treasury1 in consultation with the     
,inspector ,general of the ,department  
of ,health and ,human ,services1 the    
,inspector ,general of the ,department  
of ,labor1 and the ,inspector ,general  
of the ,department of the ,treasury1    
shall issue a compliance program        
guidance document to help improve       
compliance with this section1 section   
#gab of the ,employee ,retirement       
,income ,security ,act of #aigd1 and    
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable4 ,in      
carrying out this paragraph1 the        
,secretaries may take into consideration
 the #bjaf publication of the           
,department of ,health and ,human       

,services and the ,department of ,labor1
 entitled ,warning ,signs - ,plan or    
,policy ,non-,quantitative ,treatment   
,limitations 7,n,q,t,ls7 that ,require  
,additional ,analysis to ,determine     
,mental ,health ,parity ,compliance4    
7,b7 ,examples illustrating compliance  
and noncompliance  7i7 ,in general ,the 
compliance program guidance document    
required under this paragraph shall     
provide illustrative1 de-identified     
examples 7that do not disclose any      
protected health information or         
individually identifiable information7  
of previous findings of compliance and  
noncompliance with this section1 section
 #gab of the ,employee ,retirement      
,income ,security ,act of #aigd1 or     
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable1 based on 
investigations of violations of such    
sections1 including-- 7,i7 examples     
illustrating requirements for           
information disclosures and             
nonquantitative treatment limitations2  

and  7,,ii7 descriptions of the         
violations uncovered during the course  
of such investigations4  7ii7           
,nonquantitative treatment limitations  
,to the extent that any example         
described in clause 7i7 involves a      
finding of compliance or noncompliance  
with regard to any requirement for      
nonquantitative treatment limitations1  
the example shall provide sufficient    
detail to fully explain such finding1   
including a full description of the     
criteria involved for approving medical 
and surgical benefits and the criteria  
involved for approving mental health and
 substance use disorder benefits4  7iii7
 ,access to additional information      
regarding compliance ,in developing and 
issuing the compliance program guidance 
document required under this paragraph1 
the ,secretaries specified in           
subparagraph 7,a7-- 7,i7 shall enter    
into interagency agreements with the    
,inspector ,general of the ,department  
of ,health and ,human ,services1 the    

,inspector ,general of the ,department  
of ,labor1 and the ,inspector ,general  
of the ,department of the ,treasury to  
share findings of compliance and        
noncompliance with this section1 section
 #gab of the ,employee ,retirement      
,income ,security ,act of #aigd1 or     
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable2 and      
7,,ii7 shall seek to enter into an      
agreement with a ,state to share        
information on findings of compliance   
and noncompliance with this section1    
section #gab of the ,employee           
,retirement ,income ,security ,act of   
#aigd1 or section #ihab of the ,internal
 ,revenue ,code of #aihf1 as applicable4
  7,c7 ,recommendations ,the compliance 
program guidance document shall include 
recommendations to advance compliance   
with this section1 section #gab of the  
,employee ,retirement ,income ,security 
,act of #aigd1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable1 and encourage the           

development and use of internal controls
 to monitor adherence to applicable     
statutes1 regulations1 and program      
requirements4 ,such internal controls   
may include illustrative examples of    
nonquantitative treatment limitations on
 mental health and substance use        
disorder benefits1 which may fail to    
comply with this section1 section #gab  
of the ,employee ,retirement ,income    
,security ,act of #aigd1 or section     
#ihab of the ,internal ,revenue ,code of
 #aihf1 as applicable1 in relation to   
nonquantitative treatment limitations on
 medical and surgical benefits4  7,d7   
,updating the compliance program        
guidance document ,the ,secretary1 the  
,secretary of ,labor1 and the ,secretary
 of the ,treasury1 in consultation with 
the ,inspector ,general of the          
,department of ,health and ,human       
,services1 the ,inspector ,general of   
the ,department of ,labor1 and the      
,inspector ,general of the ,department  
of the ,treasury1 shall update the      

compliance program guidance document    
every #b years to include illustrative1 
de-identified examples 7that do not     
disclose any protected health           
information or individually identifiable
 information7 of previous findings of   
compliance and noncompliance with this  
section1 section #gab of the ,employee  
,retirement ,income ,security ,act of   
#aigd1 or section #ihab of the ,internal
 ,revenue ,code of #aihf1 as applicable4
  7#g7 ,additional guidance  7,a7 ,in   
general ,not later than #ab months after
 the date of enactment of the ,helping  
,families in ,mental ,health ,crisis    
,reform ,act of #bjaf1 the ,secretary1  
the ,secretary of ,labor1 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     
section1 section #gab of the ,employee  
,retirement ,income ,security ,act of   

#aigd1 or section #ihab of the ,internal
 ,revenue ,code of #aihf1 as applicable4
  7,b7 ,disclosure  7i7 ,guidance for   
plans and issuers ,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 section1 section #gab of the       
,employee ,retirement ,income ,security 
,act of #aigd1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable1 7and any regulations        
promulgated pursuant to such sections1  
as applicable74  7ii7 ,documents for    
participants1 beneficiaries1 contracting
 providers1 or authorized               
representatives ,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 participant1 beneficiary1           
contracting provider1 or authorized     
representative1 as applicable1 with     
documents containing information that   
the health plans or issuers are required
 to disclose to participants1           
beneficiaries1 contracting providers1 or
 authorized representatives to ensure   
compliance with this section1 section   
#gab of the ,employee ,retirement       
,income ,security ,act of #aigd1 or     
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable1          
compliance with any regulation issued   
pursuant to such respective section1 or 
compliance with any other applicable law
 or regulation4 ,such guidance shall    
include information that is comparative 
in nature with respect to-- 7,i7        
nonquantitative treatment limitations   
for both medical and surgical benefits  
and mental health and substance use     

disorder benefits2  7,,ii7 the          
processes1 strategies1 evidentiary      
standards1 and other factors used to    
apply the limitations described in      
subclause 7,i72 and  7,,iii7 the        
application of the limitations described
 in subclause 7,i7 to ensure that such  
limitations are applied in parity with  
respect to both medical and surgical    
benefits and mental health and substance
 use disorder benefits4  7,c7           
,nonquantitative treatment limitations  
,the guidance issued under this         
paragraph shall include clarifying      
information and illustrative examples of
 methods1 processes1 strategies1        
evidentiary standards1 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 section1 section #gab of the       
,employee ,retirement ,income ,security 

,act of #aigd1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable1 7and any regulations        
promulgated pursuant to such respective 
section71 including-- 7i7 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 benefits1   
including nonquantitative treatment     
limitations pertaining to-- 7,i7 medical
 management standards based on medical  
necessity or appropriateness1 or whether
 a treatment is experimental or         
investigative2  7,,ii7 limitations with 
respect to prescription drug formulary  
design2 and  7,,iii7 use of fail-first  
or step therapy protocols2  7ii7        
examples of methods of determining--    
7,i7 network admission standards 7such  
as credentialing72 and  7,,ii7 factors  
used in provider reimbursement          
methodologies 7such as service type1    
geographic market1 demand for services1 

and provider supply1 practice size1     
training1 experience1 and licensure7 as 
such factors apply to network adequacy2 
7iii7 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 limitations2  7iv7 examples of
 specific factors1 and the evidentiary  
standards used to evaluate such factors1
 used by such plans or issuers in       
performing a nonquantitative treatment  
limitation analysis2  7v7 examples of   
how specific evidentiary standards may  
be used to determine whether treatments 
are considered experimental or          
investigative2  7vi7 examples of how    
specific evidentiary standards may be   
applied to each service category or     
classification of benefits2  7vii7      
examples of methods of reaching         
appropriate coverage determinations for 
new mental health or substance use      
disorder treatments1 such as            

evidence-based early intervention       
programs for individuals with a serious 
mental illness and types of medical     
management techniques2  7viii7 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 benefit1   
such as residential treatment or        
hospitalizations involving voluntary or 
involuntary commitment2 and  7ix7       
additional illustrative examples of     
methods1 processes1 strategies1         
evidentiary standards1 and other factors
 for which the ,secretary determines    
that additional guidance is necessary to
 improve compliance with this section1  
section #gab of the ,employee           
,retirement ,income ,security ,act of   
#aigd1 or section #ihab of the ,internal
 ,revenue ,code of #aihf1 as applicable4
  7,d7 ,public comment ,prior to issuing
 any final guidance under this          

paragraph1 the ,secretary shall provide 
a public comment period of not less than
 #fj days during which any member of the
 public may provide comments on a draft 
of the guidance4  7#h7 ,compliance      
requirements  7,a7 ,nonquantitative     
treatment limitation 7,,nqtl7           
requirements ,in the case of a group    
health plan or a health insurance issuer
 offering group or individual health    
insurance coverage that provides both   
medical and surgical benefits and mental
 health or substance use disorder       
benefits and that imposes               
nonquantitative treatment limitations   
7referred to in this section as ,,nqtl7 
on mental health or substance use       
disorder benefits1 the plan or issuer   
offering health insurance coverage shall
 perform comparative analyses of the    
design and application of ,n,q,t,ls in  
accordance with subparagraph 7,b71 and1 
beginning #de days after the date of    
enactment of this paragraph1 make       
available to the applicable ,state      

authority 7or1 as applicable1 the       
,secretary71 upon request1 the          
comparative analyses and the following  
information3 7i7 ,the specific plan or  
coverage terms regarding the ,,nqtl1    
that applies to such plan or coverage1  
and a description of all mental health  
or substance use disorder and medical or
 surgical benefits to which it applies  
in each respective benefits             
classification4  7ii7 ,the factors used 
to determine that the ,,nqtl will apply 
to mental health or substance use       
disorder benefits and medical or        
surgical benefits4  7iii7 ,the          
evidentiary standards used for the      
factors identified in clause 7ii71 when 
applicable1 provided that every factor  
shall be defined and any other source or
 evidence relied upon to design and     
apply the ,,nqtl to mental health or    
substance use disorder benefits and     
medical or surgical benefits4  7iv7 ,the
 comparative analyses demonstrating that
 the processes1 strategies1 evidentiary 

standards1 and other factors used to    
design the ,,nqtl1 as written1 and the  
operation processes and strategies as   
written and in operation that are used  
to apply the ,,nqtl for mental health or
 substance use disorder benefits are    
comparable to1 and are applied no more  
stringently than1 the processes1        
strategies1 evidentiary standards1 and  
other factors used to design the ,,nqtl1
 as written1 and the operation processes
 and strategies as written and in       
operation that are used to apply the    
,,nqtl to medical or surgical benefits4 
7v7 ,a disclosure of the specific       
findings and conclusions reached by the 
plan or coverage that the results of the
 analyses described in this subparagraph
 indicate that the plan or coverage is  
in compliance with this section4  7,b7  
,secretary request process  7i7         
,submission upon request ,the ,secretary
 shall request that a group health plan 
or a health insurance issuer offering   
group or individual health insurance    

coverage submit the comparative analyses
 described in subparagraph 7,a7 for     
plans that involve potential violations 
of this section or complaints regarding 
noncompliance with this section that    
concern ,n,q,t,ls and any other         
instances in which the ,secretary       
determines appropriate4 ,the ,secretary 
shall request not fewer than #bj such   
analyses per year4  7ii7 ,additional    
information ,in instances in which the  
,secretary has concluded that the plan  
or coverage has not submitted sufficient
 information for the ,secretary to      
review the comparative analyses         
described in subparagraph 7,a71 as      
requested under clause 7i71 the         
,secretary shall specify to the plan or 
coverage the information the plan or    
coverage must submit to be responsive to
 the request under clause 7i7 for the   
,secretary to review the comparative    
analyses described in subparagraph7,a7  
for compliance with this section4       
,nothing in this paragraph shall require

 the ,secretary to conclude that a plan 
is in compliance with this section      
solely based upon the inspection of the 
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i74  7iii7 ,required action     
7,i7 ,in general ,in instances in which 
the ,secretary has reviewed the         
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i71 and determined that the plan
 or coverage is not in compliance with  
this section1 the plan or coverage--    
7aa7 shall specify to the ,secretary the
 actions the plan or coverage will take 
to be in compliance with this section   
and provide to the ,secretary           
comparative analyses described in       
subparagraph 7,a7 that demonstrate      
compliance with this section not later  
than #de days after the initial         
determination by the ,secretary that the
 plan or coverage is not in compliance2 
and  7bb7 following the #de-;day        
corrective action period under item     

7aa71 if the ,secretary determines that 
the plan or coverage still is not in    
compliance with this section1 not later 
than #g days after such determination1  
shall notify all individuals enrolled in
 the plan or coverage that the plan or  
coverage has been determined to be not  
in compliance with this section4  7,,ii7
 ,exemption from disclosure ,documents  
or communications produced in connection
 with the ,secretary's recommendations  
to the plan or coverage shall not be    
subject to disclosure pursuant to       
section #eeb of title #e1 ,united       
,states ,code4  7iv7 ,report ,not later 
than #a year after the date of enactment
 of this paragraph1 and not later than  
,october #a of each year thereafter1 the
 ,secretary shall submit to ,congress1  
and make publicly available1 a report   
that contains-- 7,i7 a summary of the   
comparative analyses requested under    
clause 7i71 including the identity of   
each plan or coverage that is determined
 to be not in compliance after the final

 determination by the ,secretary        
described in clause 7iii77,i77bb72      
7,,ii7 the ,secretary's conclusions as  
to whether each plan or coverage        
submitted sufficient information for the
 ,secretary to review the comparative   
analyses requested under clause 7i7 for 
compliance with this section2  7,,iii7  
for each plan or coverage that did      
submit sufficient information for the   
,secretary to review the comparative    
analyses requested under clause 7i71 the
 ,secretary's conclusions as to whether 
and why the plan or coverage is in      
compliance with the requirements under  
this section2  7,,iv7 the ,secretary's  
specifications described in clause 7ii7 
for each plan or coverage that the      
,secretary determined did not submit    
sufficient information for the          
,secretary to review the comparative    
analyses requested under clause 7i7 for 
compliance with this section2 and  7,v7 
the ,secretary's specifications         
described in clause 7iii7 of the actions

 each plan or coverage that the         
,secretary determined is not in         
compliance with this section must take  
to be in compliance with this section1  
including the reason why the ,secretary 
determined the plan or coverage is not  
in compliance4  7,c7 ,compliance program
 guidance document update process  7i7  
,in general ,the ,secretary shall       
include instances of noncompliance that 
the ,secretary discovers upon reviewing 
the comparative analyses requested under
 subparagraph 7,b77i7 in the compliance 
program guidance document described in  
paragraph 7#f71 as it is updated every  
#b years1 except that such instances    
shall not disclose any protected health 
information or individually identifiable
 information4  7ii7 ,guidance and       
regulations ,not later than #ah months  
after the date of enactment of this     
paragraph1 the ,secretary shall finalize
 any draft or interim guidance and      
regulations relating to mental health   
parity under this section4 ,such draft  

guidance shall include 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 plans to 
file complaints of such plans or issuers
 being in violation of this section1    
including guidance1 by plan type1 on the
 relevant ,state1 regional1 or national 
office with which such complaints should
 be filed4  7iii7 ,state ,the ,secretary
 shall share information on findings of 
compliance and noncompliance discovered 
upon reviewing the comparative analyses 
requested under subparagraph 7,b77i7    
with the ,state where the group health  
plan is located or the ,state where the 
health insurance issuer is licensed to  
do business for coverage offered by a   
health insurance issuer in the group    
market1 in accordance with paragraph    
7#f77;,b77iii77,,ii74  7b7 ,construction
 ,nothing in this section shall be      

construed-- 7#a7 as requiring a group   
health plan or a health insurance issuer
 offering group or individual health    
insurance coverage to provide any mental
 health or substance use disorder       
benefits2 or  7#b7 in the case of a     
group health plan or a health insurance 
issuer offering group or individual     
health insurance coverage that provides 
mental health or substance use disorder 
benefits1 as affecting the terms and    
conditions of the plan or coverage      
relating to such benefits under the plan
 or coverage1 except as provided in     
subsection 7a74  7c7 ,exemptions  7#a7  
,small employer exemption ,this section 
shall not apply to any group health plan
 and a health insurance issuer offering 
group or individual health insurance    
coverage for any plan year of a small   
employer 7as defined in section         
#bgia7;e77#d71 except that for purposes 
of this paragraph such term shall       
include employers with #a employee in   
the case of an employer residing in a   

,state that permits small groups to     
include a single individual74  7#b7     
,cost exemption  7,a7 ,in general ,with 
respect to a group health plan or a     
health insurance issuer offering group  
or individual health insurance coverage1
 if the application of this section to  
such plan 7or coverage7 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 7as    
determined and certified under          
subparagraph 7,c77 by an amount that    
exceeds the applicable percentage       
described in subparagraph 7,b7 of the   
actual total plan costs1 the provisions 
of this section shall not apply to such 
plan 7or coverage7 during the following 
plan year1 and such exemption shall     
apply to the plan 7or coverage7 for #a  
plan year4 ,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 7or coverage7 involved
 regardless of any increase in total    
costs4  7,b7 ,applicable percentage     
,with respect to a plan 7or coverage71  
the applicable percentage described in  
this subparagraph shall be-- 7i7 #b     
percent in the case of the first plan   
year in which this section is applied2  
and  7ii7 #a percent in the case of each
 subsequent plan year4  7,c7            
,determinations by actuaries            
,determinations as to increases in      
actual costs under a plan 7or coverage7 
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  
,actuaries4 ,all such determinations    
shall be in a written report prepared by
 the actuary4 ,the report1 and all      
underlying documentation relied upon by 
the actuary1 shall be maintained by the 
group health plan or health insurance   
issuer for a period of #f years         

following the notification made under   
subparagraph 7,e74  7,d7 #f-month       
determinations ,if a group health plan  
7or a health insurance issuer offering  
coverage in connection with a group     
health plan7 seeks an exemption under   
this paragraph1 determinations under    
subparagraph 7,a7 shall be made after   
such plan 7or coverage7 has complied    
with this section for the first #f      
months of the plan year involved4  7,e7 
,notification  7i7 ,in general ,a group 
health plan 7or a health insurance      
issuer offering coverage in connection  
with a group health plan7 that1 based   
upon a certification described under    
subparagraph 7,c71 qualifies for an     
exemption under this paragraph1 and     
elects to implement the exemption1 shall
 promptly notify the ,secretary1 the    
appropriate ,state agencies1 and        
participants and beneficiaries in the   
plan of such election4  7ii7            
,requirement ,a notification to the     
,secretary under clause 7i7 shall       

include-- 7,i7 a description of the     
number of covered lives under the plan  
7or coverage7 involved at the time of   
the notification1 and as applicable1 at 
the time of any prior election of the   
cost-exemption under this paragraph by  
such plan 7or coverage72  7,,ii7 for    
both the plan year upon which a cost    
exemption is sought and the year prior1 
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 plan2 and  7,,iii7 for both the plan
 year upon which a cost exemption is    
sought and the year prior1 the actual   
total costs of coverage with respect to 
mental health and substance use disorder
 benefits under the plan4  7iii7        
,confidentiality ,a notification to the 
,secretary under clause 7i7 shall be    
confidential4 ,the ,secretary shall make
 available1 upon request and on not more
 than an annual basis1 an anonymous     
itemization of such notifications1 that 

includes-- 7,i7 a breakdown of ,states  
by the size and type of employers       
submitting such notification2 and       
7,,ii7 a summary of the data received   
under clause 7ii74  7,f7 ,audits by     
appropriate agencies ,to determine      
compliance with this paragraph1 the     
,secretary may audit the books and      
records of a group health plan or health
 insurance issuer relating to an        
exemption1 including any actuarial      
reports prepared pursuant to            
subparagraph 7,c71 during the #f year   
period following the notification of    
such exemption under subparagraph 7,e74 
,a ,state agency receiving a            
notification under subparagraph 7,e7 may
 also conduct such an audit with respect
 to an exemption covered by such        
notification4  7d7 ,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 plan1 the requirements of this      

section shall be applied separately with
 respect to each such option4  7e7      
,definitions ,for purposes of this      
section-- 7#a7 ,aggregate lifetime limit
 ,the term aggregate lifetime limit     
means1 with respect to benefits under a 
group health plan or health insurance   
coverage1 a dollar limitation on the    
total amount that may be paid with      
respect to such benefits under the plan 
or health insurance coverage with       
respect to an individual or other       
coverage unit4  7#b7 ,annual limit ,the 
term annual limit means1 with respect to
 benefits under a group health plan or  
health insurance coverage1 a dollar     
limitation on the total amount of       
benefits that may be paid with respect  
to such benefits in a #ab-month period  
under the plan or health insurance      
coverage with respect to an individual  
or other coverage unit4  7#c7 ,medical  
or surgical benefits ,the term medical  
or surgical benefits means benefits with
 respect to medical or surgical         

services1 as defined under the terms of 
the plan or coverage 7as the case may   
be71 but does not include mental health 
or substance use disorder benefits4     
7#d7 ,mental health benefits ,the term  
mental health benefits means benefits   
with respect to services for mental     
health conditions1 as defined under the 
terms of the plan and in accordance with
 applicable ,federal and ,state law4    
7#e7 ,substance use disorder benefits   
,the term substance use disorder        
benefits means benefits with respect to 
services for substance use disorders1 as
 defined under the terms of the plan and
 in accordance with applicable ,federal 
and ,state law4  4  7#b7 ,sunset        
,section #bgbf of the ,public ,health   
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#bf7 is amended by adding at the
 end the following new subsection  7f7  
,sunset ,the provisions of this section 
shall have no force or effect after the 
date of the enactment of the            
,strengthening ,behavioral ,health      

,parity ,act4  4  7#c7 ,administration2 
conforming amendments  7,a7 ,application
 of implementation regulations ,the     
provisions of sections #adf4acf and     
#adg4afj of title #de1 ,code of ,federal
 ,regulations shall apply to section    
#bgii;,a-#a of the ,public ,health      
,service ,act1 as added by paragraph    
7#a71 in the same manner as such        
provisions applied to section #bgbf of  
the ,public ,health ,service ,act 7#db  
,u4,s4,c4 #cjj;gg-#bf7 before the date  
of the enactment of this ,act4  7,b7    
,conforming amendments  7i7 ,section    
#bgbb of the ,public ,health ,service   
,act 7#db ,u4,s4,c4 #cjj;gg-#ba7 is     
amended-- 7,i7 in subsection 7a77#a71 by
 inserting and part ,d after subparts #a
 and #b2  7,,ii7 in subsection 7b71 by  
inserting and part ,d after subparts #a 
and #b2  7,,iii7 in subsection 7c77#a71 
by inserting and part ,d after subparts 
#a and #b2  7,,iv7 in subsection        
7c77#b71 by inserting and part ,d after 
subparts #a and #b2  7,v7 in subsection 

7c77#c71 by inserting and part ,d after 
this part2 and  7,,vi7 in subsection    
7d71 in the matter preceding paragraph  
7#a71 by inserting and part ,d after    
this part4  7ii7 ,section #bgbc of the  
,public ,health ,service ,act 7#db      
,u4,s4,c4 #cjj;gg-#bb7 is amended-- 7,i7
 in subsection 7a77#a71 by inserting and
 part ,d after this part2  7,,ii7 in    
subsection 7a77#b71 by inserting or part
 ,d after this part2  7,,iii7 in        
subsection 7b77#a71 by inserting or part
 ,d after this part2  7,,iv7 in         
subsection 7b77#b77;,a71 by inserting or
 part ,d after this part2 and  7,v7 in  
subsection 7b77#b77;,c77ii71 by         
inserting and part ,d after this part4  
7iii7 ,section #bgbd of the ,public     
,health ,service ,act 7#db ,u4,s4,c4    
#cjj;gg-#bc7 is amended-- 7,i7 in       
subsection 7a77#a7-- 7aa7 by striking   
this part and part ,c insofar as it     
relates to this part and inserting this 
part1 part ,d1 and part ,c insofar as it
 relates to this part or part ,d2 and   

7bb7 by inserting or part ,d after      
requirement of this part2  7,,ii7 in    
subsection 7a77#b71 by inserting or part
 ,d after this part2 and  7,,iii7 in    
subsection 7c71 by inserting or part ,d 
after this part 7other than section     
#bgjd74  7b7 ,,erisa ,section #gab7;a7  
of the ,employee ,retirement ,income    
,security ,act of #aigd 7#aahe;a7a77 is 
amended by adding at the end the        
following new paragraphs3  7#f7         
,compliance program guidance document   
7,a7 ,in general ,not later than #ab    
months after the date of enactment of   
the ,helping ,families in ,mental       
,health ,crisis ,reform ,act of #bjaf1  
the ,secretary1 the ,secretary of       
,health and ,human ,services1 and the   
,secretary of the ,treasury1 in         
consultation with the ,inspector        
,general of the ,department of ,health  
and ,human ,services1 the ,inspector    
,general of the ,department of ,labor1  
and the ,inspector ,general of the      
,department of the ,treasury1 shall     

issue a compliance program guidance     
document to help improve compliance with
 this section1 section #bgii;,a-#a of   
the ,public ,health ,service ,act1 and  
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable4 ,in      
carrying out this paragraph1 the        
,secretaries may take into consideration
 the #bjaf publication of the           
,department of ,health and ,human       
,services and the ,department of ,labor1
 entitled ,warning ,signs - ,plan or    
,policy ,non-,quantitative ,treatment   
,limitations 7,n,q,t,ls7 that ,require  
,additional ,analysis to ,determine     
,mental ,health ,parity ,compliance4    
7,b7 ,examples illustrating compliance  
and noncompliance  7i7 ,in general ,the 
compliance program guidance document    
required under this paragraph shall     
provide illustrative1 de-identified     
examples 7that do not disclose any      
protected health information or         
individually identifiable information7  
of previous findings of compliance and  

noncompliance with this section1 section
 #bgii;,a-#a of the ,public ,health     
,service ,act1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable1 based on investigations of  
violations of such sections1 including--
 7,i7 examples illustrating requirements
 for information disclosures and        
nonquantitative treatment limitations2  
and  7,,ii7 descriptions of the         
violations uncovered during the course  
of such investigations4  7ii7           
,nonquantitative treatment limitations  
,to the extent that any example         
described in clause 7i7 involves a      
finding of compliance or noncompliance  
with regard to any requirement for      
nonquantitative treatment limitations1  
the example shall provide sufficient    
detail to fully explain such finding1   
including a full description of the     
criteria involved for approving medical 
and surgical benefits and the criteria  
involved for approving mental health and
 substance use disorder benefits4  7iii7

 ,access to additional information      
regarding compliance ,in developing and 
issuing the compliance program guidance 
document required under this paragraph1 
the ,secretaries specified in           
subparagraph 7,a7-- 7,i7 shall enter    
into interagency agreements with the    
,inspector ,general of the ,department  
of ,health and ,human ,services1 the    
,inspector ,general of the ,department  
of ,labor1 and the ,inspector ,general  
of the ,department of the ,treasury to  
share findings of compliance and        
noncompliance with this section1 section
 #bgii;,a-#a of the ,public ,health     
,service ,act1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable2 and  7,,ii7 shall seek to   
enter into an agreement with a ,state to
 share information on findings of       
compliance and noncompliance with this  
section1 section #bgii;,a-#a of the     
,public ,health ,service ,act1 or       
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable4  7,c7    

,recommendations ,the compliance program
 guidance document shall include        
recommendations to advance compliance   
with this section1 section #bgii;,a-#a  
of the ,public ,health ,service ,act1 or
 section #ihab of the ,internal ,revenue
 ,code of #aihf1 as applicable1 and     
encourage the development and use of    
internal controls to monitor adherence  
to applicable statutes1 regulations1 and
 program requirements4 ,such internal   
controls may include illustrative       
examples of nonquantitative treatment   
limitations on mental health and        
substance use disorder benefits1 which  
may fail to comply with this section1   
section #bgii;,a-#a of the ,public      
,health ,service ,act1 or section #ihab 
of the ,internal ,revenue ,code of      
#aihf1 as applicable1 in relation to    
nonquantitative treatment limitations on
 medical and surgical benefits4  7,d7   
,updating the compliance program        
guidance document ,the ,secretary1 the  
,secretary of ,health and ,human        

,services1 and the ,secretary of the    
,treasury1 in consultation with the     
,inspector ,general of the ,department  
of ,health and ,human ,services1 the    
,inspector ,general of the ,department  
of ,labor1 and the ,inspector ,general  
of the ,department of the ,treasury1    
shall update the compliance program     
guidance document every #b years to     
include illustrative1 de-identified     
examples 7that do not disclose any      
protected health information or         
individually identifiable information7  
of previous findings of compliance and  
noncompliance with this section1 section
 #bgii;,a-#a of the ,public ,health     
,service ,act1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable4  7#g7 ,additional guidance  
7,a7 ,in general ,not later than #ab    
months after the date of enactment of   
the ,helping ,families in ,mental       
,health ,crisis ,reform ,act of #bjaf1  
the ,secretary1 the ,secretary of       
,health and ,human ,services1 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     
section1 section #bgii;,a-#a of the     
,public ,health ,service ,act1 or       
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable4  7,b7    
,disclosure  7i7 ,guidance for plans and
 issuers ,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 section1 section #bgii;,a-#a 
of the ,public ,health ,service ,act1 or
 section #ihab of the ,internal ,revenue
 ,code of #aihf1 as applicable1 7and any
 regulations promulgated pursuant to    
such sections1 as applicable74  7ii7    

,documents for participants1            
beneficiaries1 contracting providers1 or
 authorized representatives ,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 participant1 beneficiary1   
contracting provider1 or authorized     
representative1 as applicable1 with     
documents containing information that   
the health plans or issuers are required
 to disclose to participants1           
beneficiaries1 contracting providers1 or
 authorized representatives to ensure   
compliance with this section1 section   
#bgii;,a-#a of the ,public ,health      
,service ,act1 or section #ihab of the  
,internal ,revenue ,code of #aihf1 as   
applicable1 compliance with any         
regulation issued pursuant to such      
respective section1 or compliance with  
any other applicable law or regulation4 

,such guidance shall include information
 that is comparative in nature with     
respect to-- 7,i7 nonquantitative       
treatment limitations for both medical  
and surgical benefits and mental health 
and substance use disorder benefits2    
7,,ii7 the processes1 strategies1       
evidentiary standards1 and other factors
 used to apply the limitations described
 in subclause 7,i72 and  7,,iii7 the    
application of the limitations described
 in subclause 7,i7 to ensure that such  
limitations are applied in parity with  
respect to both medical and surgical    
benefits and mental health and substance
 use disorder benefits4  7,c7           
,nonquantitative treatment limitations  
,the guidance issued under this         
paragraph shall include clarifying      
information and illustrative examples of
 methods1 processes1 strategies1        
evidentiary standards1 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 section1 section #bgii;,a-#a of the
 ,public ,health ,service ,act1 or      
section #ihab of the ,internal ,revenue 
,code of #aihf1 as applicable1 7and any 
regulations promulgated pursuant to such
 respective section71 including-- 7i7   
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
 benefits1 including nonquantitative    
treatment limitations pertaining to--   
7,i7 medical management standards based 
on medical necessity or appropriateness1
 or whether a treatment is experimental 
or investigative2  7,,ii7 limitations   
with respect to prescription drug       
formulary design2 and  7,,iii7 use of   
fail-first or step therapy protocols2   
7ii7 examples of methods of             
determining-- 7,i7 network admission    

standards 7such as credentialing72 and  
7,,ii7 factors used in provider         
reimbursement methodologies 7such as    
service type1 geographic market1 demand 
for services1 and provider supply1      
practice size1 training1 experience1 and
 licensure7 as such factors apply to    
network adequacy2  7iii7 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 limitations2  
7iv7 examples of specific factors1 and  
the evidentiary standards used to       
evaluate such factors1 used by such     
plans or issuers in performing a        
nonquantitative treatment limitation    
analysis2  7v7 examples of how specific 
evidentiary standards may be used to    
determine whether treatments are        
considered experimental or              
investigative2  7vi7 examples of how    
specific evidentiary standards may be   
applied to each service category or     

classification of benefits2  7vii7      
examples of methods of reaching         
appropriate coverage determinations for 
new mental health or substance use      
disorder treatments1 such as            
evidence-based early intervention       
programs for individuals with a serious 
mental illness and types of medical     
management techniques2  7viii7 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 benefit1   
such as residential treatment or        
hospitalizations involving voluntary or 
involuntary commitment2 and  7ix7       
additional illustrative examples of     
methods1 processes1 strategies1         
evidentiary standards1 and other factors
 for which the ,secretary determines    
that additional guidance is necessary to
 improve compliance with this section1  
section #bgii;,a-#a of the ,public      

,health ,service ,act1 or section #ihab 
of the ,internal ,revenue ,code of      
#aihf1 as applicable4  7,d7 ,public     
comment ,prior to issuing any final     
guidance under this paragraph1 the      
,secretary shall provide a public       
comment period of not less than #fj days
 during which any member of the public  
may provide comments on a draft of the  
guidance4  7#h7 ,compliance requirements
  7,a7 ,nonquantitative treatment       
limitation 7,,nqtl7 requirements        
,beginning #de days after the date of   
enactment of this paragraph1 in the case
 of a group health plan or a health     
insurance issuer offering group health  
insurance coverage that provides both   
medical and surgical benefits and mental
 health or substance use disorder       
benefits and that imposes               
nonquantitative treatment limitations   
7referred to in this section as ,,nqtl7 
on mental health or substance use       
disorder benefits1 the plan or issuer   
offering health insurance coverage shall

 perform comparative analyses of the    
design and application of ,n,q,t,ls in  
accordance with subparagraph 7,b71 and  
make available to the applicable ,state 
authority 7or1 as applicable1 the       
,secretary71 upon request1 the following
 information3 7i7 ,the specific plan or 
coverage terms regarding the ,,nqtl1    
that applies to such plan or coverage1  
and a description of all mental health  
or substance use disorder and medical or
 surgical benefits to which it applies  
in each respective benefits             
classification4  7ii7 ,the factors used 
to determine that the ,,nqtl will apply 
to mental health or substance use       
disorder benefits and medical or        
surgical benefits4  7iii7 ,the          
evidentiary standards used for the      
factors identified in clause 7ii71 when 
applicable1 provided that every factor  
shall be defined and any other source or
 evidence relied upon to design and     
apply the ,,nqtl to mental health or    
substance use disorder benefits and     

medical or surgical benefits4  7iv7 ,the
 comparative analyses demonstrating that
 the processes1 strategies1 evidentiary 
standards1 and other factors used to    
design the ,,nqtl1 as written1 and the  
operation processes and strategies as   
written and in operation that are used  
to apply the ,,nqtl for mental health or
 substance use disorder benefits are    
comparable to1 and are applied no more  
stringently than1 the processes1        
strategies1 evidentiary standards1 and  
other factors used to design the ,,nqtl1
 as written1 and the operation processes
 and strategies as written and in       
operation that are used to apply the    
,,nqtl to medical or surgical benefits4 
7v7 ,a disclosure of the specific       
findings and conclusions reached by the 
plan or coverage that the results of the
 analyses described in this subparagraph
 indicate that the plan or coverage is  
in compliance with this section4  7,b7  
,secretary request process  7i7         
,submission upon request ,the ,secretary

 shall request that a group health plan 
or a health insurance issuer offering   
group health insurance coverage submit  
the comparative analyses described in   
subparagraph 7,a7 for plans that involve
 potential violations of this section or
 complaints regarding noncompliance with
 this section that concern ,n,q,t,ls and
 any other instances in which the       
,secretary determines appropriate4 ,the 
,secretary shall request not fewer than 
#bj such analyses per year4  7ii7       
,additional information ,in instances in
 which the ,secretary has concluded that
 the plan or coverage has not submitted 
sufficient information for the          
,secretary to review the comparative    
analyses described in subparagraph 7,a71
 as requested under clause 7i71 the     
,secretary shall specify to the plan or 
coverage the information the plan or    
coverage must submit to be responsive to
 the request under clause 7i7 for the   
,secretary to review the comparative    
analyses described in subparagraph7,a7  

for compliance with this section4       
,nothing in this paragraph shall require
 the ,secretary to conclude that a plan 
is in compliance with this section      
solely based upon the inspection of the 
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i74  7iii7 ,required action     
7,i7 ,in general ,in instances in which 
the ,secretary has reviewed the         
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i71 and determined that the plan
 or coverage is not in compliance with  
this section1 the plan or coverage--    
7aa7 shall specify to the ,secretary the
 actions the plan or coverage will take 
to be in compliance with this section   
and provide to the ,secretary           
comparative analyses described in       
subparagraph 7,a7 that demonstrate      
compliance with this section not later  
than #de days after the initial         
determination by the ,secretary that the
 plan or coverage is not in compliance2 

and  7bb7 following the #de-;day        
corrective action period under item     
7aa71 if the ,secretary determines that 
the plan or coverage still is not in    
compliance with this section1 not later 
than #g days after such determination1  
shall notify all individuals enrolled in
 the plan or coverage that the plan or  
coverage has been determined to be not  
in compliance with this section4  7,,ii7
 ,exemption from disclosure ,documents  
or communications produced in connection
 with the ,secretary's recommendations  
to the plan or coverage shall not be    
subject to disclosure pursuant to       
section #eeb of title #e1 ,united       
,states ,code4  7iv7 ,report ,not later 
than #a year after the date of enactment
 of this paragraph1 and not later than  
,october #a of each year thereafter1 the
 ,secretary shall submit to ,congress1  
and make publicly available1 a report   
that contains-- 7,i7 a summary of the   
comparative analyses requested under    
clause 7i71 including the identity of   

each plan or coverage that is determined
 to be not in compliance after the final
 determination by the ,secretary        
described in clause 7iii77,i77bb72      
7,,ii7 the ,secretary's conclusions as  
to whether each plan or coverage        
submitted sufficient information for the
 ,secretary to review the comparative   
analyses requested under clause 7i7 for 
compliance with this section2  7,,iii7  
for each plan or coverage that did      
submit sufficient information for the   
,secretary to review the comparative    
analyses requested under clause 7i71 the
 ,secretary's conclusions as to whether 
and why the plan or coverage is in      
compliance with the requirements under  
this section2  7,,iv7 the ,secretary's  
specifications described in clause 7ii7 
for each plan or coverage that the      
,secretary determined did not submit    
sufficient information for the          
,secretary to review the comparative    
analyses requested under clause 7i7 for 
compliance with this section2 and  7,v7 

the ,secretary's specifications         
described in clause 7iii7 of the actions
 each plan or coverage that the         
,secretary determined is not in         
compliance with this section must take  
to be in compliance with this section1  
including the reason why the ,secretary 
determined the plan or coverage is not  
in compliance4  7,c7 ,compliance program
 guidance document update process  7i7  
,in general ,the ,secretary shall       
include instances of noncompliance that 
the ,secretary discovers upon reviewing 
the comparative analyses requested under
 subparagraph 7,b77i7 in the compliance 
program guidance document described in  
paragraph 7#f71 as it is updated every  
#b years1 except that such instances    
shall not disclose any protected health 
information or individually identifiable
 information4  7ii7 ,guidance and       
regulations ,not later than #ah months  
after the date of enactment of this     
paragraph1 the ,secretary shall finalize
 any draft or interim guidance and      

regulations relating to mental health   
parity under this section4 ,such draft  
guidance shall include 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 plans to 
file complaints of such plans or issuers
 being in violation of this section1    
including guidance1 by plan type1 on the
 relevant ,state1 regional1 or national 
office with which such complaints should
 be filed4  7iii7 ,state ,the ,secretary
 shall share information on findings of 
compliance and noncompliance discovered 
upon reviewing the comparative analyses 
requested under subparagraph 7,b77i7    
with the ,state where the group health  
plan is located or the ,state where the 
health insurance issuer is licensed to  
do business for coverage offered by a   
health insurance issuer in the group    
market1 in accordance with paragraph    

7#f77;,b77iii77,,ii74  4  7c7 ,,irc     
,section #ihab of the ,internal ,revenue
 ,code of #aihf is amended by adding at 
the end the following new paragraphs3   
7#f7 ,compliance program guidance       
document  7,a7 ,in general ,not later   
than #ab months after the date of       
enactment of the ,helping ,families in  
,mental ,health ,crisis ,reform ,act of 
#bjaf1 the ,secretary1 the ,secretary of
 ,labor1 and the ,secretary of ,health  
and ,human ,services1 in consultation   
with the ,inspector ,general of the     
,department of ,health and ,human       
,services1 the ,inspector ,general of   
the ,department of ,labor1 and the      
,inspector ,general of the ,department  
of the ,treasury1 shall issue a         
compliance program guidance document to 
help improve compliance with this       
section1 section #gab of the ,employee  
,retirement ,income ,security ,act of   
#aigd1 and section #bgii;,a-#a of the   
,public ,health ,service ,act1 as       
applicable4 ,in carrying out this       

paragraph1 the ,secretaries may take    
into consideration the #bjaf publication
 of the ,department of ,health and      
,human ,services and the ,department of 
,labor1 entitled ,warning ,signs - ,plan
 or ,policy ,non-,quantitative          
,treatment ,limitations 7,n,q,t,ls7 that
 ,require ,additional ,analysis to      
,determine ,mental ,health ,parity      
,compliance4  7,b7 ,examples            
illustrating compliance and             
noncompliance  7i7 ,in general ,the     
compliance program guidance document    
required under this paragraph shall     
provide illustrative1 de-identified     
examples 7that do not disclose any      
protected health information or         
individually identifiable information7  
of previous findings of compliance and  
noncompliance with this section1 section
 #gab of the ,employee ,retirement      
,income ,security ,act of #aigd1 or     
section #bgii;,a-#a of the ,public      
,health ,service ,act1 as applicable1   
based on investigations of violations of

 such sections1 including-- 7,i7        
examples illustrating requirements for  
information disclosures and             
nonquantitative treatment limitations2  
and  7,,ii7 descriptions of the         
violations uncovered during the course  
of such investigations4  7ii7           
,nonquantitative treatment limitations  
,to the extent that any example         
described in clause 7i7 involves a      
finding of compliance or noncompliance  
with regard to any requirement for      
nonquantitative treatment limitations1  
the example shall provide sufficient    
detail to fully explain such finding1   
including a full description of the     
criteria involved for approving medical 
and surgical benefits and the criteria  
involved for approving mental health and
 substance use disorder benefits4  7iii7
 ,access to additional information      
regarding compliance ,in developing and 
issuing the compliance program guidance 
document required under this paragraph1 
the ,secretaries specified in           

subparagraph 7,a7-- 7,i7 shall enter    
into interagency agreements with the    
,inspector ,general of the ,department  
of ,health and ,human ,services1 the    
,inspector ,general of the ,department  
of ,labor1 and the ,inspector ,general  
of the ,department of the ,treasury to  
share findings of compliance and        
noncompliance with this section1 section
 #gab of the ,employee ,retirement      
,income ,security ,act of #aigd1 or     
section #bgii;,a-#a of the ,public      
,health ,service ,act1 as applicable2   
and  7,,ii7 shall seek to enter into an 
agreement with a ,state to share        
information on findings of compliance   
and noncompliance with this section1    
section #gab of the ,employee           
,retirement ,income ,security ,act of   
#aigd1 or section #bgii;,a-#a of the    
,public ,health ,service ,act1 as       
applicable4  7,c7 ,recommendations ,the 
compliance program guidance document    
shall include recommendations to advance
 compliance with this section1 section  

#gab of the ,employee ,retirement       
,income ,security ,act of #aigd1 or     
section #bgii;,a-#a of the ,public      
,health ,service ,act1 as applicable1   
and encourage the development and use of
 internal controls to monitor adherence 
to applicable statutes1 regulations1 and
 program requirements4 ,such internal   
controls may include illustrative       
examples of nonquantitative treatment   
limitations on mental health and        
substance use disorder benefits1 which  
may fail to comply with this section1   
section #gab of the ,employee           
,retirement ,income ,security ,act of   
#aigd1 or section #bgii;,a-#a of the    
,public ,health ,service ,act1 as       
applicable1 in relation to              
nonquantitative treatment limitations on
 medical and surgical benefits4  7,d7   
,updating the compliance program        
guidance document ,the ,secretary1 the  
,secretary of ,labor1 and the ,secretary
 of ,health and ,human ,services1 in    
consultation with the ,inspector        

,general of the ,department of ,health  
and ,human ,services1 the ,inspector    
,general of the ,department of ,labor1  
and the ,inspector ,general of the      
,department of the ,treasury1 shall     
update the compliance program guidance  
document every #b years to include      
illustrative1 de-identified examples    
7that do not disclose any protected     
health information or individually      
identifiable information7 of previous   
findings of compliance and noncompliance
 with this section1 section #gab of the 
,employee ,retirement ,income ,security 
,act of #aigd1 or section #bgii;,a-#a of
 the ,public ,health ,service ,act1 as  
applicable4  7#g7 ,additional guidance  
7,a7 ,in general ,not later than #ab    
months after the date of enactment of   
the ,helping ,families in ,mental       
,health ,crisis ,reform ,act of #bjaf1  
the ,secretary1 the ,secretary of       
,labor1 and the ,secretary of ,health   
and ,human ,services 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     
section1 section #gab of the ,employee  
,retirement ,income ,security ,act of   
#aigd1 or section #bgii;,a-#a of the    
,public ,health ,service ,act1 as       
applicable4  7,b7 ,disclosure  7i7      
,guidance for plans and issuers ,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 section1 section #gab of the       
,employee ,retirement ,income ,security 
,act of #aigd1 or section #bgii;,a-#a of
 the ,public ,health ,service ,act1 7and
 any regulations promulgated pursuant to
 such sections1 as applicable74  7ii7   
,documents for participants1            

beneficiaries1 contracting providers1 or
 authorized representatives ,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 participant1 beneficiary1   
contracting provider1 or authorized     
representative1 as applicable1 with     
documents containing information that   
the health plans or issuers are required
 to disclose to participants1           
beneficiaries1 contracting providers1 or
 authorized representatives to ensure   
compliance with this section1 section   
#gab of the ,employee ,retirement       
,income ,security ,act of #aigd1 or     
section #bgii;,a-#a of the ,public      
,health ,service ,act1 as applicable1   
compliance with any regulation issued   
pursuant to such respective section1 or 
compliance with any other applicable law
 or regulation4 ,such guidance shall    

include information that is comparative 
in nature with respect to-- 7,i7        
nonquantitative treatment limitations   
for both medical and surgical benefits  
and mental health and substance use     
disorder benefits2  7,,ii7 the          
processes1 strategies1 evidentiary      
standards1 and other factors used to    
apply the limitations described in      
subclause 7,i72 and  7,,iii7 the        
application of the limitations described
 in subclause 7,i7 to ensure that such  
limitations are applied in parity with  
respect to both medical and surgical    
benefits and mental health and substance
 use disorder benefits4  7,c7           
,nonquantitative treatment limitations  
,the guidance issued under this         
paragraph shall include clarifying      
information and illustrative examples of
 methods1 processes1 strategies1        
evidentiary standards1 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 section1 section #gab of the       
,employee ,retirement ,income ,security 
,act of #aigd1 or section #bgii;,a-#a of
 the ,public ,health ,service ,act1 as  
applicable1 7and any regulations        
promulgated pursuant to such respective 
section71 including-- 7i7 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 benefits1   
including nonquantitative treatment     
limitations pertaining to-- 7,i7 medical
 management standards based on medical  
necessity or appropriateness1 or whether
 a treatment is experimental or         
investigative2  7,,ii7 limitations with 
respect to prescription drug formulary  
design2 and  7,,iii7 use of fail-first  
or step therapy protocols2  7ii7        
examples of methods of determining--    

7,i7 network admission standards 7such  
as credentialing72 and  7,,ii7 factors  
used in provider reimbursement          
methodologies 7such as service type1    
geographic market1 demand for services1 
and provider supply1 practice size1     
training1 experience1 and licensure7 as 
such factors apply to network adequacy2 
7iii7 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 limitations2  7iv7 examples of
 specific factors1 and the evidentiary  
standards used to evaluate such factors1
 used by such plans or issuers in       
performing a nonquantitative treatment  
limitation analysis2  7v7 examples of   
how specific evidentiary standards may  
be used to determine whether treatments 
are considered experimental or          
investigative2  7vi7 examples of how    
specific evidentiary standards may be   
applied to each service category or     

classification of benefits2  7vii7      
examples of methods of reaching         
appropriate coverage determinations for 
new mental health or substance use      
disorder treatments1 such as            
evidence-based early intervention       
programs for individuals with a serious 
mental illness and types of medical     
management techniques2  7viii7 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 benefit1   
such as residential treatment or        
hospitalizations involving voluntary or 
involuntary commitment2 and  7ix7       
additional illustrative examples of     
methods1 processes1 strategies1         
evidentiary standards1 and other factors
 for which the ,secretary determines    
that additional guidance is necessary to
 improve compliance with this section1  
section #gab of the ,employee           

,retirement ,income ,security ,act of   
#aigd1 or section #bgii;,a-#a of the    
,public ,health ,service ,act1 as       
applicable4  7,d7 ,public comment ,prior
 to issuing any final guidance under    
this paragraph1 the ,secretary shall    
provide a public comment period of not  
less than #fj days during which any     
member of the public may provide        
comments on a draft of the guidance4    
7#h7 ,compliance requirements  7,a7     
,nonquantitative treatment limitation   
7,,nqtl7 requirements ,beginning #de    
days after the date of enactment of this
 paragraph1 in the case of a group      
health plan that provides both medical  
and surgical benefits and mental health 
or substance use disorder benefits and  
that imposes nonquantitative treatment  
limitations 7referred to in this section
 as ,,nqtl7 on mental health or         
substance use disorder benefits1 the    
plan shall perform comparative analyses 
of the design and application of        
,n,q,t,ls in accordance with            

subparagraph 7,b71 and make available to
 the applicable ,state authority 7or1 as
 applicable1 the ,secretary71 upon      
request1 the following information3 7i7 
,the specific plan terms regarding the  
,,nqtl1 that applies to such plan or    
coverage1 and a description of all      
mental health or substance use disorder 
and medical or surgical benefits to     
which it applies in each respective     
benefits classification4  7ii7 ,the     
factors used to determine that the      
,,nqtl will apply to mental health or   
substance use disorder benefits and     
medical or surgical benefits4  7iii7    
,the evidentiary standards used for the 
factors identified in clause 7ii71 when 
applicable1 provided that every factor  
shall be defined and any other source or
 evidence relied upon to design and     
apply the ,,nqtl to mental health or    
substance use disorder benefits and     
medical or surgical benefits4  7iv7 ,the
 comparative analyses demonstrating that
 the processes1 strategies1 evidentiary 

standards1 and other factors used to    
design the ,,nqtl1 as written1 and the  
operation processes and strategies as   
written and in operation that are used  
to apply the ,,nqtl for mental health or
 substance use disorder benefits are    
comparable to1 and are applied no more  
stringently than1 the processes1        
strategies1 evidentiary standards1 and  
other factors used to design the ,,nqtl1
 as written1 and the operation processes
 and strategies as written and in       
operation that are used to apply the    
,,nqtl to medical or surgical benefits4 
7v7 ,a disclosure of the specific       
findings and conclusions reached by the 
plan that the results of the analyses   
described in this subparagraph indicate 
that the plan is in compliance with this
 section4  7,b7 ,secretary request      
process  7i7 ,submission upon request   
,the ,secretary shall request that a    
group health plan submit the comparative
 analyses described in subparagraph 7,a7
 for plans that involve potential       

violations of this section or complaints
 regarding noncompliance with this      
section that concern ,n,q,t,ls and any  
other instances in which the ,secretary 
determines appropriate4 ,the ,secretary 
shall request not fewer than #bj such   
analyses per year4  7ii7 ,additional    
information ,in instances in which the  
,secretary has concluded that the plan  
has not submitted sufficient information
 for the ,secretary to review the       
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i71 the ,secretary shall specify
 to the plan the information the plan or
 coverage must submit to be responsive  
to the request under clause 7i7 for the 
,secretary to review the comparative    
analyses described in subparagraph7,a7  
for compliance with this section4       
,nothing in this paragraph shall require
 the ,secretary to conclude that a plan 
is in compliance with this section      
solely based upon the inspection of the 
comparative analyses described in       

subparagraph 7,a71 as requested under   
clause 7i74  7iii7 ,required action     
7,i7 ,in general ,in instances in which 
the ,secretary has reviewed the         
comparative analyses described in       
subparagraph 7,a71 as requested under   
clause 7i71 and determined that the plan
 is not in compliance with this section1
 the plan-- 7aa7 shall specify to the   
,secretary the actions the plan will    
take to be in compliance with this      
section and provide to the ,secretary   
comparative analyses described in       
subparagraph 7,a7 that demonstrate      
compliance with this section not later  
than #de days after the initial         
determination by the ,secretary that the
 plan is not in compliance2 and  7bb7   
following the #de-;day corrective action
 period under item 7aa71 if the         
,secretary determines that the plan     
still is not in compliance with this    
section1 not later than #g days after   
such determination1 shall notify all    
individuals enrolled in the plan or     

coverage that the plan has been         
determined to be not in compliance with 
this section4  7,,ii7 ,exemption from   
disclosure ,documents or communications 
produced in connection with the         
,secretary's recommendations to the plan
 or coverage shall not be subject to    
disclosure pursuant to section #eeb of  
title #e1 ,united ,states ,code4  7iv7  
,report ,not later than #a year after   
the date of enactment of this paragraph1
 and not later than ,october #a of each 
year thereafter1 the ,secretary shall   
submit to ,congress1 and make publicly  
available1 a report that contains-- 7,i7
 a summary of the comparative analyses  
requested under clause 7i71 including   
the identity of each plan that is       
determined to be not in compliance after
 the final determination by the         
,secretary described in clause          
7iii77,i77bb72  7,,ii7 the ,secretary's 
conclusions as to whether each plan     
submitted sufficient information for the
 ,secretary to review the comparative   

analyses requested under clause 7i7 for 
compliance with this section2  7,,iii7  
for each plan that did submit sufficient
 information for the ,secretary to      
review the comparative analyses         
requested under clause 7i71 the         
,secretary's conclusions as to whether  
and why the plan or coverage is in      
compliance with the requirements under  
this section2  7,,iv7 the ,secretary's  
specifications described in clause 7ii7 
for each plan that the ,secretary       
determined did not submit sufficient    
information for the ,secretary to review
 the comparative analyses requested     
under clause 7i7 for compliance with    
this section2 and  7,v7 the ,secretary's
 specifications described in clause     
7iii7 of the actions each plan hat the  
,secretary determined is not in         
compliance with this section must take  
to be in compliance with this section1  
including the reason why the ,secretary 
determined the plan or coverage is not  
in compliance4  7,c7 ,compliance program

 guidance document update process  7i7  
,in general ,the ,secretary shall       
include instances of noncompliance that 
the ,secretary discovers upon reviewing 
the comparative analyses requested under
 subparagraph 7,b77i7 in the compliance 
program guidance document described in  
paragraph 7#f71 as it is updated every  
#b years1 except that such instances    
shall not disclose any protected health 
information or individually identifiable
 information4  7ii7 ,guidance and       
regulations ,not later than #ah months  
after the date of enactment of this     
paragraph1 the ,secretary shall finalize
 any draft or interim guidance and      
regulations relating to mental health   
parity under this section4 ,such draft  
guidance shall include 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 plans to 

file complaints of such plans or issuers
 being in violation of this section1    
including guidance1 by plan type1 on the
 relevant ,state1 regional1 or national 
office with which such complaints should
 be filed4  7iii7 ,state ,the ,secretary
 shall share information on findings of 
compliance and noncompliance discovered 
upon reviewing the comparative analyses 
requested under subparagraph 7,b77i7    
with the ,state where the group health  
plan is located or the ,state where the 
health insurance issuer is licensed to  
do business for coverage offered by a   
health insurance issuer in the group    
market1 in accordance with paragraph    
7#f77;,b77iii77,,ii74  4  7d7           
,implementation ,the ,secretary of      
,health and ,human ,services1 the       
,secretary of ,labor1 and the ,secretary
 of the ,treasury may implement the     
paragraph 7#h7 of section               
#bgii;,a-#a7;a7 of the ,public ,health  
,service ,act1 added by subsection 7a71 
the paragraph 7#h7 of section #gab7;a7  

of the ,employee ,retirement ,income    
,security ,act of #aigd1 as addedby     
subsection 7b71 and the paragraph 7#h7  
of section #ihab7;a7 of the ,internal   
,revenue ,code of #aihf1 as added by    
subsection 7c71 by program instruction1 
guidance1 or otherwise4  ,december #bd1 
#bjbj,reported from the ,committee on   
,energy and ,commerce with an           
amendment,december #bd1                 
#bjbj;,committees on ,ways and ,means   
and ,education and ,labor discharged2   
committed to the ,committee of the      
,whole ,house on the ,state of the      
,union and ordered to be printed