12 2 STA T .38 8 9PUBLIC LA W 11 0– 3 4 3 —O CT. 3 , 2008 trea t m e n t , n u m b er ofvis its, d a y sof c overa g e,orot h er simi l ar limits on the sco p e or duration of treatment .‘ ‘ (4)AVAIL A B ILI TYOFP LA N INFO RM ATION. —T he criteria for medical necessity determinations made under the plan w ith respect to mental health or substance use disorder benefits shall be made available by the plan administrator in accordance with regulations to any current or potential participant, bene - ficiary, or contracting provider upon re q uest. The reason for any denial under the plan 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 to the participant or beneficiary in accordance with regulations. ‘‘( 5 ) OU T-OF-N E T W OR K PROVI D ER S .— I nthecaseofaplan that provides both medical and surgical benefits and mental health or substance use disorder benefits, if the plan provides coverage for medical or surgical benefits provided by out-of- networ k providers, the plan 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 section. ’ ’
( 2 ) in subsection (b), by amending paragraph (2) to read as follows
‘‘(2) in the case of a group health plan that provides mental health or substance use disorder benefits, as affecting the terms and conditions of the plan relating to such benefits under the plan, e x cept as provided in subsection (a).’’; ( 3 ) in subsection (c)— (A) by amending paragraph ( 1 ) to read as follows: ‘‘(1) S MALL EMPLOYER E X EMPTION.— ‘‘(A) IN G ENERAL.—This section shall not apply to any group health plan for any plan year of a small employer. ‘‘( B ) SMALL EMPLOYER.— F or purposes of subparagraph (A), the term ‘small employer’ means, with respect to a calendar year and a plan year, an employer who employed an average of at least 2 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 5 0 employees on business days during the preceding calendar year. For pur- poses of the preceding sentence, all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 shall be treated as 1 employer and rules similar to rules of subparagraphs (B) and ( C ) of section 4 98 0 D (d)(2) shall apply.’’; and (B) by striking paragraph (2) and inserting the fol- lowing: ‘‘(2) COST EXEMPTION.— ‘‘(A) IN GENERAL.— W ith respect to a group health plan, if the application of this section to such plan results in an increase for the plan year involved of the actual total costs of coverage with respect to medical and surgical bene- fits and mental health and substance use disorder benefits under the plan (as determined and certified under subpara- graph (C)) by an amount that exceeds the applicable percentage described in subparagraph (B) of the actual total plan costs, the provisions of this section shall not Ap p licab ili ty. Applicability.
�
