About This Policy: Health Care Services and Financing: Health Insurance Parity for Alcohol-Related Treatment

Period Covered: 1/1/2003 through 1/1/2022

This policy topic covers laws addressing requirements that health plans provide the same levels of benefits for alcohol-related disorders as they do for medical and surgical conditions.

Note: The secondary literature and the laws and regulations related to this policy topic use a variety of terms that are sometimes used in different ways by different jurisdictions. To see definitions for these terms as they are used in APIS, see the Definitions heading below.

Parity for treatment of alcohol-related disorders refers to State and Federal requirements that health plans provide the same levels of benefits for these disorders as they do for medical and surgical conditions. "The same" may be defined in terms of deductibles, co-payments, or other types of cost sharing; annual or lifetime service limits; annual or lifetime payouts; or any combination of these. Some jurisdictions have adopted parity provisions that specifically apply to alcohol-related disorders. Other jurisdictions have parity provisions for general mental health care or substance abuse disorders, either of which may or may not include alcohol-related disorders. APIS addresses only those laws that pertain specifically to parity for treatment of alcohol-related disorders.

Parity laws are a relatively recent development. When health care costs began rising sharply in the 1970s and 1980s, many health plans tightened coverage for mental health care. By the early 1990s, significant disparities had emerged between medical and surgical coverage and mental health coverage, often including coverage for alcohol-related disorders or any type of substance abuse. In response, the Federal government and many States have passed legislation requiring some type of parity.

The Affordable Care Act (ACA) is an important recent piece of Federal legislation that is changing the landscape of health insurance parity. For more information on the ACA and other Federal laws, see the Federal Law page for this policy topic.

Note: The secondary literature and the laws and regulations related to this policy topic use a variety of terms that are sometimes used in different ways by different jurisdictions. Definitions for these terms as they are used in APIS are provided below.

Relevant Definitions Related to Health Insurance Parity for Alcohol-Related Treatment.[1].

1. All definitions come from the online glossary maintained by the U.S. Centers for Medicare & Medicaid Services, located at https://www.healthcare.gov/glossary/.

Explanatory Notes and Limitations Specifically Applicable to Health Insurance Parity for Alcohol-Related Treatment

1. Parity provisions that do not use the word "alcohol" may nonetheless apply to alcohol-related disorders. Provisions that reference disorders listed in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) are sufficient because alcohol abuse and dependence are included in the DSM's classification of mental disorders. Definitions for "substance abuse," "chemical dependency," and "mental illness" vary across jurisdictions, so reference to those definitions or other clarifying language may be necessary to determine whether the provisions apply to alcohol-related disorders.
2. Certain States have enacted provisions designed to bring their insurance laws into conformity with the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Federal Mental Health Parity Act of 1996 (MHPA) and the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). These provisions do not require mental health or substance use disorder benefits coverage. However, if a plan offers coverage for mental health or substance use disorder benefits, then these benefits must be equal to physical illness benefits in certain respects. Such provisions are not coded in APIS.
3. The APIS analysis of Health Insurance Parity for Alcohol-Related Treatment addresses statutes and regulations regarding large group health plans. This analysis does not consider or include the following types of policies or plans:
   • Individual (as opposed to group) plans
   • Small group plans, defined as employment-based plans that include no more than 100 employees (however the law allows exceptions such that in some States, until 2016, small groups are defined as having no more than 50 employees)
   • Disability income plans (income protection in the event the covered person becomes disabled)
   • Accidental death or dismemberment plans
   • Plans that only provide coverage for a specified disease
   • Medicare supplement policies
   • Workers' compensation coverage
   • Medical payment coverage issued as part of a motor vehicle insurance policy
   • Long term care policies, including nursing home fixed indemnity policies
   • Self-insured plans (self-funded plans in which an employer is at risk for the medical expenses of its own employees)
   • State-sponsored assigned risk insurance pools, for residents denied adequate health insurance (generally because of existing health problems) or for persons without insurance but meeting certain Federal eligibility requirements
4. This analysis does not include State medical assistance provisions (State-sponsored or State-administered health plans available to low income individuals).
5. This analysis does not include any interactions between parity laws and mandates of the following Federal programs: Temporary Assistance to Needy Families (TANF), Medicaid, Medicare, Social Security Income (SSI).
6. The analysis does not comprehensively address requirements that pertain exclusively to State employee health plans. However, the research found that none of the States without parity provisions for alcohol-related treatment impose alcohol-related parity requirements on their State employee health plans.

Explanatory Notes and Limitations Applicable to All APIS Policy Topics

1. State law may permit local jurisdictions to impose requirements in addition to those mandated by State law. Alternatively, State law may prohibit local legislation on this topic, thereby preempting local powers. For more information on the preemption doctrine, see the About Alcohol Policy page. APIS does not document policies established by local governments.
2. In addition to statutes and regulations, judicial decisions (case law) also may affect alcohol-related policies. APIS does not review case law except to determine whether judicial decisions have invalidated statutes or regulations that would otherwise affect the data presented in the comparison tables.
3. APIS reviews published administrative regulations. However, administrative decisions or directives that are not included in a State's published regulatory codes may have an impact on implementation. This possibility has not been addressed by the APIS research.
4. Statutes and regulations cited in tables on this policy topic may have been amended or repealed after the specific date or time period specified by the site user's search criteria.
5. The operation or enforcement of statutes or regulations affecting the policies addressed on APIS may have been suspended or modified by executive or administrative orders issued in response to the COVID-19 pandemic. With the exception of the COVID-19 Digest and Dataset, APIS research does not address these orders or the effects they may have on the policies covered by APIS.
6. Policy changes in APIS are presented as of the date these changes take effect as law. Users should be aware that in some situations there may be a delay between the effective date of a law and the time a corresponding policy change occurs in practice. Because APIS research is based entirely on primary legal source materials (codified statutes and regulations and, on rare occasions, published court opinions), APIS is unable to accurately determine when policy changes may appear in practice.
7. If a conflict exists between a statute and a regulation addressing the same legal issue, APIS coding relies on the statute.
8. A comprehensive understanding of the data presented in the comparison tables for this policy topic requires examination of the applicable Row Notes and Jurisdiction Notes, which can be accessed from the body of the table via links in the Jurisdiction column.

(Policies in effect on:  1/1/2022)

Although the laws relating to health insurance have traditionally been State-based, with rules created by State legislatures and administrative agencies and interpreted by State courts, the Federal government has become increasingly involved in recent years.

For example, on October 3, 2008 Congress passed and the President signed the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Rules implementing MHPAEA became effective on April 5, 2010 for plan years beginning on or after July 1, 2010 (see 26 C.F.R. § 54.9812-1, 29 C.F.R. § 2590.712, and 45 C.F.R. § 146.136).

MHPAEA mandated that if an employer of more than 50 persons provides substance use disorder benefits through a group health plan, those benefits must be equal in certain respects to the medical and surgical benefits provided by that plan. (For details, see the Relevant Text Excerpts below.) Importantly, however, MHPAEA did not require plans to provide substance use disorder benefits.

MHPAEA amended the 1996 Mental Health Parity Act (MHPA), which included parity provisions for mental health care but specifically excluded substance abuse or chemical dependency benefits. Congress first adopted parity provisions in the Health Insurance Portability and Accountability Act (HIPAA) and then a few months later amended those provisions with the MHPA.

MHPAEA modified several Federal laws, including the Public Health Service (PHS) Act and the Employee Retirement Income Security Program (ERISA). The respective PHS Act provisions (42 U.S.C. § 300gg-26) generally apply to group health plans, to health insurance issuers offering group or individual health insurance coverage, and to certain State and local government plans. The ERISA provisions (29 U.S.C. § 1185a) generally apply to all group health plans other than governmental plans, church plans, and certain other plans. The provisions differ only slightly to reflect the scope of each Act.

The Affordable Care Act (ACA), signed into law on March 23, 2010, and amended March 30, 2010, has expanded the reach of MHPAEA. Effective for plan years beginning on or after January 1, 2014, the ACA requires all small group and individual market plans created after March 23, 2010, to comply with Federal parity requirements. Specifically, Qualified Health Plans offered through the Health Insurance Marketplaces for individual and small group plans in every State must include coverage for mental health and substance use disorders, including alcohol-related disorders, as one of ten categories of Essential Health Benefits, and this coverage must comply with the Federal parity requirements set forth in MHPAEA. The ACA may produce further changes to health insurance parity as additional rules are enacted and implemented in the future.

For purposes of parity, there are three types of insurance plans: small group plans (employment-based plans that include no more than 50 employees); large group plans (employment-based plans that include 51 or more employees); and individual plans (which are not employment-based and which individuals purchase directly from an insurance company). Small group plans created before March 23, 2010, will be "grandfathered" and will not be subject to the requirements of MHPAEA. APIS only addresses provisions that apply to large group health plans, not provisions applicable solely to small group or individual plans.

In general, Federal law has a limiting effect on the applicability of State parity rules due to the doctrine of Federal preemption, which is derived from the Supremacy Clause of the United States Constitution (U.S. Const. art. VI, cl. 2). Because of this doctrine, State laws that do not provide for substance use disorder benefits, or parity for substance use disorder benefits, on terms at least as favorable as provided under Federal law would likely be held preempted by Federal law if challenged in court. For more information on the preemption doctrine, see the About Alcohol Policy page.

FEDERAL CITATIONS AND RELEVANT TEXT EXCERPTS

U.S. Const. art. VI, cl. 2

* * *

This Constitution, and the laws of the United States which shall be made in pursuance thereof; and all treaties made, or which shall be made, under the authority of the United States, shall be the supreme law of the land; and the judges in every State shall be bound thereby, anything in the Constitution or laws of any State to the contrary notwithstanding.

* * *

29 U.S.C. § 1185a
United States Code
Title 29 - LABOR
CHAPTER 18 - EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM
SUBCHAPTER I - PROTECTION OF EMPLOYEE BENEFIT RIGHTS
Subtitle B - Regulatory Provisions
Part 7 - group health plan requirements
Subpart B - Other Requirements
§ 1185a. Parity in mental health and substance use disorder benefits

• (a) In general
  • (1) Aggregate lifetime limits
  • In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits—
    • (A) No lifetime limit
    • If the plan or coverage does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate lifetime limit on mental health or substance use disorder benefits.
    • (B) Lifetime limit
    • If the plan or coverage includes an aggregate lifetime limit on substantially all medical and surgical benefits (in this paragraph referred to as the “applicable lifetime limit”), the plan or coverage shall either—
      • (i) 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 benefits; or
      • (ii) not include any aggregate lifetime limit on mental health or substance use disorder benefits that is less than the applicable lifetime limit.
    • (C) Rule in case of different limits
    • In the case of a plan or coverage that is not described in subparagraph (A) or (B) and that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) 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 categories.
  • (2) Annual limits
  • In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits—
    • (A) No annual limit
    • If the plan or coverage does not include an annual limit on substantially all medical and surgical benefits, the plan or coverage may not impose any annual limit on mental health or substance use disorder benefits.
    • (B) Annual limit
    • If the plan or coverage includes an annual limit on substantially all medical and surgical benefits (in this paragraph referred to as the “applicable annual limit”), the plan or coverage shall either—
      • (i) 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 benefits; or
      • (ii) not include any annual limit on mental health or substance use disorder benefits that is less than the applicable annual limit.
    • (C) Rule in case of different limits
    • In the case of a plan or coverage that is not described in subparagraph (A) or (B) and that includes no or different annual limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) 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 categories.
  • (3) Financial requirements and treatment limitations
    • (A) In general
    • In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that—
      • (i) 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 (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 substance use disorder benefits.
    • (B) Definitions
    • In this paragraph:
      • (i) Financial requirement
      • The term “financial requirement” includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit subject to paragraphs (1) and (2),1
      • (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 “treatment 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) Availability of plan 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 provider 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.
  • (5) 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 benefits, if the plan or coverage provides coverage for medical or surgical benefits provided by out-of-network providers, 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 section.
  • * * *
• (b) Construction
• Nothing in this section shall be construed—
  • (1) as requiring a group health plan (or health insurance coverage offered in connection with such a plan) to provide any mental health or substance use disorder benefits; or
  • (2) in the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides mental health or substance use disorder benefits, as affecting the terms and conditions of the plan or coverage relating to such benefits under the plan or coverage, except as provided in subsection (a).
• (c) Exemptions
  • (1) Small employer exemption
    • (A) In general
    • This section shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year of a small employer.
    • (B) Small employer
    • For purposes of subparagraph (A), the term “small employer” means, in connection with a group health plan 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 50 employees on business days during the preceding calendar year.
    • (C) Application of certain rules in determination of employer size
    • For purposes of this paragraph—
      • (i) Application of aggregation rule for employers
      • Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 of title 26 shall apply for purposes of treating persons as a single employer.
      • (ii) Employers not in existence in preceding year
      • In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
      • (iii) Predecessors
      • Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer.
  • (2) Cost exemption
    • (A) In general
    • With respect to a group health plan (or health insurance coverage offered in connection with such a plan), if the application of this section to such plan (or coverage) 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 (as determined and certified under subparagraph (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 apply to such plan (or coverage) during the following plan year, and such exemption shall apply to the plan (or coverage) for 1 plan year. 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 (or coverage) involved regardless of any increase in total costs.
    • (B) Applicable percentage
    • With respect to a plan (or coverage), the applicable percentage described in this subparagraph shall be—
      • (i) 2 percent in the case of the first plan year in which this section is applied; and
      • (ii) 1 percent in the case of each subsequent plan year.
    • (C) Determinations by actuaries
    • Determinations as to increases in actual costs under a plan (or coverage) 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 Actuaries. All such determinations shall be in a written report prepared by the actuary. The report, and all underlying documentation relied upon by the actuary, shall be maintained by the group health plan or health insurance issuer for a period of 6 years following the notification made under subparagraph (E).
    • (D) 6-month determinations
    • If a group health plan (or a health insurance issuer offering coverage in connection with a group health plan) seeks an exemption under this paragraph, determinations under subparagraph (A) shall be made after such plan (or coverage) has complied with this section for the first 6 months of the plan year involved.
    • (E) Notification
      • (i) In general
      • A group health plan (or a health insurance issuer offering coverage in connection with a group health plan) that, based upon a certification described under subparagraph (C), qualifies for an exemption under this paragraph, and elects to implement the exemption, shall promptly notify the Secretary, the appropriate State agencies, and participants and beneficiaries in the plan of such election.
• * * *
• (d) 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 plan, the requirements of this section shall be applied separately with respect to each such option.
• (e) Definitions
• For purposes of this section—
  • (1) Aggregate lifetime limit
  • The term “aggregate lifetime limit” means, with respect to benefits under a group health plan or health insurance coverage, 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 unit.
  • (2) Annual limit
  • The term “annual limit” means, with respect to benefits under a group health plan or health insurance coverage, a dollar limitation on the total amount of benefits that may be paid with respect to such benefits in a 12-month period under the plan or health insurance coverage with respect to an individual or other coverage unit.
  • (3) Medical or surgical benefits
  • The term “medical or surgical benefits” means benefits with respect to medical or surgical services, as defined under the terms of the plan or coverage (as the case may be), but does not include mental health or substance use disorder benefits.
  • (4) Mental health benefits
  • The term “mental health benefits” means benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable Federal and State law.
  • (5) Substance use disorder benefits
  • The term “substance use disorder benefits” means benefits with respect to services for substance use disorders, as defined under the terms of the plan and in accordance with applicable Federal and State law.
• * * *
•  

42 U.S.C. § 300gg-6
United States Code
Title 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 6A - PUBLIC HEALTH SERVICE
SUBCHAPTER XXV - REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
Part A - Individual and Group Market Reforms
Subpart I - General Reform
§ 300gg–6. Comprehensive health insurance coverage

• (a) Coverage for essential health benefits package
• A health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that such coverage includes the essential health benefits package required under section 18022(a) of this title.
• * * *

42 U.S.C. § 300gg-26
United States Code
Title 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 6A - PUBLIC HEALTH SERVICE
SUBCHAPTER XXV - REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
Part A - Individual and Group Market Reforms
Subpart 2 - Improving Coverage
§ 300gg–26. Parity in mental health and substance use disorder benefits

• (a) In general
  • (1) 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—
    • (A) No lifetime limit
    • If the plan or coverage does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate lifetime limit on mental health or substance use disorder benefits.
    • (B) Lifetime limit
    • If the plan or coverage includes an aggregate lifetime limit on substantially all medical and surgical benefits (in this paragraph referred to as the “applicable lifetime limit”), the plan or coverage shall either—
      • (i) 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 benefits; or
      • (ii) not include any aggregate lifetime limit on mental health or substance use disorder benefits that is less than the applicable lifetime limit.
    • (C) Rule in case of different limits
    • In the case of a plan or coverage that is not described in subparagraph (A) or (B) and that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) 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 categories.
  • (2) 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—
    • (A) No annual limit
    • If the plan or coverage does not include an annual limit on substantially all medical and surgical benefits, the plan or coverage may not impose any annual limit on mental health or substance use disorder benefits.
    • (B) Annual limit
    • If the plan or coverage includes an annual limit on substantially all medical and surgical benefits (in this paragraph referred to as the “applicable annual limit”), the plan or coverage shall either—
      • (i) 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 benefits; or
      • (ii) not include any annual limit on mental health or substance use disorder benefits that is less than the applicable annual limit.
    • (C) Rule in case of different limits
    • In the case of a plan or coverage that is not described in subparagraph (A) or (B) and that includes no or different annual limits on different categories of medical and surgical benefits, the Secretary shall establish rules under which subparagraph (B) 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 categories.
  • (3) Financial requirements and treatment limitations
    • (A) 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 benefits, such plan or coverage shall ensure that—
      • (i) 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 (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 substance use disorder benefits.
    • (B) Definitions
    • In this paragraph:
      • (i) Financial requirement
      • The term “financial requirement” includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit subject 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 “treatment 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) Availability of plan 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 provider 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.
  • (5) 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 benefits, if the plan or coverage provides coverage for medical or surgical benefits provided by out-of-network providers, 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 section.
  • * * *
• (b) Construction
• Nothing in this section shall be construed—
  • (1) 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 benefits; or
  • (2) 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 benefits, as affecting the terms and conditions of the plan or coverage relating to such benefits under the plan or coverage, except as provided in subsection (a).
• (c) Exemptions
  • (1) 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 (as defined in section 300gg–91(e)(4) of this title, except that for purposes of this paragraph such term shall include employers with 1 employee in the case of an employer residing in a State that permits small groups to include a single individual).
  • (2) Cost exemption
    • (A) In general
    • With respect to a group health plan or a health insurance issuer offering group or individual health insurance coverage, if the application of this section to such plan (or coverage) 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 (as determined and certified under subparagraph (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 apply to such plan (or coverage) during the following plan year, and such exemption shall apply to the plan (or coverage) for 1 plan year. 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 (or coverage) involved regardless of any increase in total costs.
    • (B) Applicable percentage
    • With respect to a plan (or coverage), the applicable percentage described in this subparagraph shall be—
      • (i) 2 percent in the case of the first plan year in which this section is applied; and
      • (ii) 1 percent in the case of each subsequent plan year.
    • (C) Determinations by actuaries
    • Determinations as to increases in actual costs under a plan (or coverage) 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 Actuaries. All such determinations shall be in a written report prepared by the actuary. The report, and all underlying documentation relied upon by the actuary, shall be maintained by the group health plan or health insurance issuer for a period of 6 years following the notification made under subparagraph (E).
    • (D) 6-month determinations
    • If a group health plan (or a health insurance issuer offering coverage in connection with a group health plan) seeks an exemption under this paragraph, determinations under subparagraph (A) shall be made after such plan (or coverage) has complied with this section for the first 6 months of the plan year involved.
    • (E) Notification
      • (i) In general
      • A group health plan (or a health insurance issuer offering coverage in connection with a group health plan) that, based upon a certification described under subparagraph (C), qualifies for an exemption under this paragraph, and elects to implement the exemption, shall promptly notify the Secretary, the appropriate State agencies, and participants and beneficiaries in the plan of such election.
• * * *
• (d) 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 plan, the requirements of this section shall be applied separately with respect to each such option.
• (e) Definitions
• For purposes of this section—
  • (1) Aggregate lifetime limit
  • The term “aggregate lifetime limit” means, with respect to benefits under a group health plan or health insurance coverage, 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 unit.
  • (2) Annual limit
  • The term “annual limit” means, with respect to benefits under a group health plan or health insurance coverage, a dollar limitation on the total amount of benefits that may be paid with respect to such benefits in a 12-month period under the plan or health insurance coverage with respect to an individual or other coverage unit.
  • (3) Medical or surgical benefits
  • The term “medical or surgical benefits” means benefits with respect to medical or surgical services, as defined under the terms of the plan or coverage (as the case may be), but does not include mental health or substance use disorder benefits.
  • (4) Mental health benefits
  • The term “mental health benefits” means benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable Federal and State law.
  • (5) Substance use disorder benefits
  • The term “substance use disorder benefits” means benefits with respect to services for substance use disorders, as defined under the terms of the plan and in accordance with applicable Federal and State law.

42 U.S.C. § 18022
United States Code
Title 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 157. Quality Affordable Health Care for All Americans
SUBCHAPTER III. Available Coverage Choices for All Americans
Part A. Establishment of Qualified Health Plans
§ 18022. Essential health benefits requirements

• (a) Essential health benefits package
• In this title, the term “essential health benefits package” means, with respect to any health plan, coverage that--
  • (1) provides for the essential health benefits defined by the Secretary under subsection (b);
  • (2) limits cost-sharing for such coverage in accordance with subsection (c); * * *
• * * *
• (b) Essential health benefits
  • (1) In general
  • Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
  • * * *
    • (E) Mental health and substance use disorder services, including behavioral health treatment.
• * * *

42 U.S.C. § 18024
United States Code
Title 42 - THE PUBLIC HEALTH AND WELFARE
CHAPTER 157. Quality Affordable Health Care for All Americans
SUBCHAPTER III. Available Coverage Choices for All Americans
Part A. Establishment of Qualified Health Plans
§ 18024. Related definitions

In this title:

(1) Group market

The term “group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by an employer.

(2) Individual market

The term “individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

(3) Large and small group markets

The terms “large group market” and “small group market” mean the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer (as defined in subsection (b)(1)) or by a small employer (as defined in subsection (b)(2)), respectively.

In this title:

(1) Large employer

The term “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.

(2) Small employer

The term “small employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 50 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.

(3) State option to extend definition of small employer

Notwithstanding paragraphs (1) and (2), nothing in this section shall prevent a State from applying this subsection by treating as a small employer, with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.

* * *

PL 111-148, 2010 HR 3590
UNITED STATES PUBLIC LAWS

111th Congress - Second Session

Convening January 05, 2010

PL 111–148 [HR 3590]

March 23, 2010

PATIENT PROTECTION AND AFFORDABLE CARE ACT

* * *

<< 42 USCA § 300gg NOTE >>

SEC. 1253. EFFECTIVE DATES.

This subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after January 1, 2014.

* * *

45 C.F.R. § 146.136
Code of Federal Regulations
Title 45. Public Welfare
Subtitle A. Department of Health and Human Services
Subchapter B. Requirements Relating to Health Care Access
Part 146. Requirements for the Group Health Insurance Market
Subpart C. Requirements Related to Benefits
§ 146.136 Parity in mental health and substance use disorder benefits.

• (a) Meaning of terms. For purposes of this section, except where the context clearly indicates otherwise, the following terms have the meanings indicated:
  • * * *
  • Mental health benefits means benefits with respect to items or services for mental health conditions, as defined under the terms of the plan or health insurance coverage and in accordance with applicable Federal and State law. Any condition defined by the plan or coverage as being or as not being a mental health condition must be defined to be consistent with generally recognized independent standards of current medical practice (for example, the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the most current version of the ICD, or State guidelines).
  • Substance use disorder benefits means benefits with respect to items or services for substance use disorders, as defined under the terms of the plan or health insurance coverage and in accordance with applicable Federal and State law. Any disorder defined by the plan as being or as not being a substance use disorder must be defined to be consistent with generally recognized independent standards of current medical practice (for example, the most current version of the DSM, the most current version of the ICD, or State guidelines).
• * * *

45 C.F.R. § 156.115
Code of Federal Regulations
Title 45. Public Welfare
Subtitle A. Department of Health and Human Services
Subchapter B. Requirements Relating to Health Care Access
Part 156. Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges
Subpart B. Essential Health Benefits Package
§ 156.115 Provision of EHB.

• (a) Provision of EHB means that a health plan provides benefits that—
  • (1) Are substantially equal to the EHB–benchmark plan including:
    • (i) Covered benefits;
    • (ii) Limitations on coverage including coverage of benefit amount, duration, and scope; and
    • (iii) Prescription drug benefits that meet the requirements of § 156.122 of this subpart;
  • * * *
  • (3) With respect to the mental health and substance use disorder services, including behavioral health treatment services, required under § 156.110(a)(5), comply with the requirements under section 2726 of the Public Health Service Act and its implementing regulations.
• * * *

Source for all citations on this page: www.govinfo.gov/, a service of the U.S. Government Publishing Office (GPO). Excerpts from the United States Code are current as of 2020. Excerpts from the Code of Federal Regulations are current as of 2022. Excerpts from Public Laws of Congress are current as of the year of enactment. The GPO’s Public Domain & Copyright Notice is available at https://www.govinfo.gov/about/policies#copyright .

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Health Care Services and Financing: Health Insurance: Losses Due to Intoxication ("UPPL")