12 2 STA T .38 8 5PUBLIC LA W 11 0– 3 4 3 —O CT. 3 , 2008 (b)AMEND MEN TS T OPUBLICH E A LT HS E RV ICE ACT .— S ection2705 o f t h eP u b l ic He a lth Se rv ice Act ( 4 2 U .S. C . 3 00 g g – 5)i s a m en d ed— ( 1 ) in subsection (a) , b y adding at the end the follo w ing
- ‘
‘(3) F INANCIAL RE Q UIREMENTS AND TREATMENT LIMITA - TIONS.— ‘‘(A) I N G ENERAL.—In the case of a grou p health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical bene- fits and mental health or substance use disorder benefits, such plan or coverage shall ensure that— ‘‘(i) the financial re q uirements 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 (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits
and ‘‘(ii) 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 (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or sub- stance use disorder benefits. ‘‘( B ) D E F INITIONS.—In this paragraph: ‘‘(i) FINANCIAL REQUIREMENT.— T he term ‘financial requirement ’ includes deductibles, copayments, coinsurance, and out-of-poc k ete x penses, but excludes an aggregate lifetime limit and an annual limit sub j ect to paragraphs (1) and (2). ‘‘(ii) 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 requirement. ‘‘(iii) TREATMENT LIMITATION.—The term ‘treat- ment limitation’ includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. ‘‘(4) AVAILABILIT Y OF P LAN INFORMATION.—The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits (or the health insurance coverage offered in connection with the plan with respect to such benefits) shall be made available by the plan administrator (or the health insurance issuer offering such coverage) in accordance with regulations to any current or potential participant, beneficiary, or contracting pro- vider upon request. The reason for any denial under the plan (or coverage) of reimbursement or payment for services with respect to mental health or substance use disorder benefits in the case of any participant or beneficiary shall, on request or as otherwise required, be made available by the plan administrator (or the health insurance issuer offering such coverage) to the participant or beneficiary in accordance with regulations.
�
