Legislation from United States of America Senate

Behavioral Health Coverage Transparency Act

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Summary
Title:

Behavioral Health Coverage Transparency Act

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05/21/19

Introduced

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Introduced in Senate

Date: May 21, 2019

Content
Code:
116.S.1576
Subject:
Health
Behavioral Health Coverage Transparency Act
Date: May 21, 2019 Official Title: To strengthen parity in mental health and substance use disorder benefits.Short title This Act may be cited as the "Behavioral Health Coverage Transparency Act".Public Health Service Act Section 2726(a) of the Public Health Service Act () is amended by adding at the end the following new paragraph:
* (i) Regulations Not later than 6 months after the date of enactment of this paragraph, the Secretary, in cooperation with the Secretaries of Labor and the Treasury, shall issue regulations for carrying out this section, including an explanation of documents that group health plans and health insurance issuers offering group or individual health insurance coverage shall disclose in accordance with clause (ii), the process governing the disclosure of such documents, and analyses that such plans and issuers shall conduct in order to demonstrate compliance with this section. * (ii) Disclosure requirements The documents required to be disclosed by a group health plan or a health insurance issuer offering group or individual health insurance under clause (i) shall include an annual report that details the specific analyses performed to ensure compliance of such plan or issuer with this section, including any regulation promulgated pursuant to this section. At a minimum, with respect to the application of nonquantitative treatment limitations (in this paragraph referred to as "NQTLs") to benefits under the plan or coverage, such report shall * (I) identify the specific factors the plan or issuer used in performing its NQTLs analysis; * (II) identify and define the specific evidentiary standards relied on to evaluate such factors; * (III) describe how the evidentiary standards are applied to each service category for mental health benefits, substance use disorder benefits, medical benefits, and surgical benefits; * (IV) disclose the results of the analyses of the specific evidentiary standards in each service category; and * (V) disclose the specific findings of the plan or issuer in each service category and the conclusions reached with respect to whether the processes, strategies, evidentiary standards, or other factors used in applying the NQTLs to mental health or substance use disorder benefits are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the NQTLs to medical and surgical benefits in the same classification. * (iii) Guidance Not later than 6 months after the date of enactment of this paragraph, the Secretary, in cooperation with the Secretaries of Labor and the Treasury, shall issue guidance to group health plans and 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 beneficiaries. Such information shall include * (I) certificate of coverage documents and instruments under which the plan or coverage involved is administered and operated that specify, include, or refer to procedures, formulas, and methodologies applied to determine a participant's or beneficiary's benefit under the plan or coverage, regardless of whether such information is contained in a document designated as the "plan document"; and * (II) a disclosure of how the plan or issuer involved has provided that processes, strategies, evidentiary stan­dards, and other factors used in applying the NQTLs to mental health or substance use disorder benefits are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the NQTLs to medical and surgical benefits in the same classification. * (iv) Definitions In this paragraph and paragraph (7), the terms , , and have the meanings given such terms in sections 146.136 and 147.160 of title 45, Code of Federal Regulations (or any successor regulation). * (i) Process for complaints Not later than 6 months after the date of enactment of this paragraph, the Secretary, in cooperation with the Secretaries of Labor and the Treasury, shall, with respect to group health plans and health insurance issuers offering group or individual health insurance coverage, issue guidance to clarify the process and timeline for current and potential participants and beneficiaries (and authorized representatives and health care providers of such participants and beneficiaries) with respect to such plans and coverage to file formal complaints of such plans or issuers being in violation of this section, including guidance, by plan type, on the relevant State, regional, and national offices with which such complaints should be filed. * (I) Randomized audits Beginning 1 year after the date of enactment of this paragraph, the Secretary, in cooperation with the Secretaries of Labor and the Treasury, as applicable, shall conduct randomized audits of group health plans and health insurance issuers offering group or individual health insurance coverage to determine compliance with this section. Such audits shall be conducted on no fewer than 12 plans or coverages per plan year. * (II) Additional audits Beginning 1 year after the date of enactment of this paragraph, 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 year, the Secretary, in cooperation with the Secretaries of Labor and the Treasury, as applicable, may audit the books and records of such plan or issuer to determine compliance with this section. * (iii) Denial rates The Secretary, in cooperation with the Secretaries of Labor and the Treasury, shall collect information on the rates of and reasons for denial by group health plans and health insurance issuers offering group or individual health insurance coverage of claims for outpatient and inpatient mental health and substance use disorder benefits compared to the rates of and reasons for denial of claims for medical and surgical benefits. For the first plan year that begins on or after the date that is 2 years after the date of enactment of this paragraph, and each subsequent plan year, the Secretary, in such cooperation, shall submit to the Committee on Energy and Commerce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate the information collected under the previous sentence with respect to the previous plan year.