SEC. 201. PARITY IN MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS UNDER MEDICARE ADVANTAGE AND PRESCRIPTION DRUG PLANS.
(a) Medicare Advantage Plans.—
(1) IN GENERAL.—Section 1852 of the Social Security Act (42 U.S.C. 1395w–22) is amended by adding at the end the following new subsection:
“(o) Parity In Mental Health And Substance Use Disorder Benefits.—
“(1) IN GENERAL.—Each MA organization shall ensure that the benefit design of each MA plan offered by such organization meets the following requirements:
“(A) FINANCIAL REQUIREMENTS.—The financial requirements applicable to mental health or substance use disorder benefits covered by the plan may not exceed the predominant financial requirements applied to substantially all medical benefits covered by the plan, including supplemental benefits, and there are no separate cost sharing requirements that are applicable only with respect to mental health and substance use disorder benefits.
“(B) TREATMENT LIMITATIONS.—The treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical benefits covered by the plan and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits, including supplemental benefits.
“(2) DETERMINATIONS OF MEDICAL NECESSITY.—
“(A) IN GENERAL.—Each MA organization shall ensure that any determination of medical necessity for mental health or substance use benefits under each MA plan offered by such organization that is not based on the application of a national or local coverage determination is consistent with generally accepted standards of mental health and substance use disorder care, as defined in paragraph. For any level of care determination with respect to mental health or substance use disorder benefits, coverage criteria are consistent with widely-used treatment guidelines only if they result in a level of care determination that is consistent with the determination that would have been made using the relevant widely-used treatment guidelines.
“(B) CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS.—The criteria for determination of medical necessity with respect to mental health or substance use disorder benefits under an MA plan shall be made available in plain language to any individual upon request.
“(3) REPORTING ON APPLICATION OF NONQUANTITATIVE TREATMENT LIMITATIONS.—
“(A) COMPARATIVE ANALYSES OF DESIGN AND APPLICATION OF NONQUANTITATIVE TREATMENT LIMITS.—For 2025 and subsequent years, in the case of an MA organization that imposes nonquantitative treatment limitations (referred to in this paragraph as ‘NQTLs’) on mental health or substance use disorder benefits under an MA plan offered by such organization, such organization shall be required to perform and document comparative analyses of the design and application of NQTLs on mental health and substance use disorder benefits under the plan and make available to the Secretary as provided under subparagraph (B), upon request, the comparative analyses and the following information:
“(i) The specific plan terms regarding the NQTLs and a description of all mental health or substance use disorder and medical benefits to which each such term applies in each respective benefits classification.
“(ii) The factors used to determine that the NQTLs will apply to mental health or substance use disorder benefits and medical benefits.
“(iii) The evidentiary standards used for the factors identified in clause (ii), when applicable, provided that every factor shall be defined, and any other source or evidence, including utilization of decision support technology, artificial intelligence technology, machine-learning technology, clinical decision-making technology, or any other technology specified by the Secretary, relied upon to design and apply the NQTLs to mental health or substance use disorder benefits and medical benefits.
“(iv) The comparative analyses demonstrating that the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to mental health or substance use disorder benefits, as written and in operation, are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to medical benefits in the benefits classification.
“(v) The specific findings and conclusions reached by the MA organization with respect to the MA plan, including any results of the analyses described in this subparagraph that indicate that the plan is or is not in compliance with this subsection.
“(B) SUBMISSION TO SECRETARY UPON REQUEST.—An MA organization shall submit to the Secretary the comparative analyses described in subparagraph (A) and the information described in clauses (i) through (v) of such subparagraph upon request by the Secretary. The Secretary shall request not fewer than 20 such analyses per year.
“(C) REPORT.—Not later than October 1, 2029, and biennially thereafter, the Secretary shall submit to Congress, and make publicly available, a report that contains the following:
“(i) A summary of the comparative analyses and information requested under subparagraph (B).
“(ii) The Secretary's conclusions as to whether each MA organization submitted sufficient information for the Secretary to review the comparative analyses and information requested for compliance with this subsection.
“(iii) The Secretary's conclusions as to whether each MA organization that submitted sufficient information for the Secretary to review was in compliance with this subsection.
“(4) DEFINITIONS.—In this subsection:
“(A) CLASSIFICATION OF BENEFITS.—The term ‘classification of benefits’ means the following:
“(i) INPATIENT.—Benefits under part A.
“(ii) OUTPATIENT.—Benefits furnished on an outpatient basis under part B.
“(iii) EMERGENCY CARE.—Benefits for emergency care covered under part B.
“(iv) PART B PRESCRIPTION DRUGS.—Benefits for drugs and biologicals covered under part B.
“(v) COVERED PART D DRUGS.—Benefits for covered part D drugs as defined in section 1860D–2(e).
“(vi) SUPPLEMENTAL.—Supplemental health care benefits as described in section 1852(a)(3).
“(B) EVIDENTIARY STANDARDS.—The term ‘evidentiary standard’ means factors or evidence a plan considers in designing and applying its medical management techniques, such as generally accepted standards of mental health and substance use disorder care, recognized medical literature, professional standards and protocols (including comparative effectiveness studies and clinical trials), published research studies, treatment guidelines created by professional medical associations or other third-party entities, publicly available or proprietary clinical definitions, and outcome metrics from consulting or other organizations.
“(C) FINANCIAL REQUIREMENT.—The term ‘financial requirement’ includes deductibles, copayments, coinsurance, and maximum limitations on out-of-pocket expenses applicable under the plan.
“(D) GENERALLY ACCEPTED STANDARDS OF MENTAL HEALTH AND SUBSTANCE USE DISORDER CARE.—The term ‘generally accepted standards of mental health and substance use disorder care’ means standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, and addiction medicine and counseling, to ensure appropriate diagnosis, treatment, and ongoing management, for underlying mental health and substance use disorders, including co-occurring conditions, to adequately meet the needs of patients. These standards are derived from valid, evidence–based sources such as peer–reviewed scientific studies and medical literature, consensus guidelines of nonprofit health care provider professional associations and specialty societies, including level of care criteria and clinical practice guidelines, and recommendations of Federal government agencies.
“(E) MENTAL HEALTH BENEFITS.—The term ‘mental health benefits’ means benefits with respect to items and services for mental health conditions as defined by the Secretary.
“(F) 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.
“(G) SUBSTANCE USE DISORDER BENEFITS.—The term ‘substance use disorder benefits’ means benefits with respect to items and services for substance use disorders as defined by the Secretary.
“(H) SUBSTANTIALLY ALL.—A financial requirement or treatment limitation applies to substantially all medical benefits in a classification if it applies to at least two-thirds of the benefits in that classification.
“(I) TREATMENT LIMITATION.—
“(i) IN GENERAL.—The term ‘treatment limitation’ means mechanisms to control utilization of services and expenditures such as limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. Such term includes:
“(I) QUANTITATIVE TREATMENT LIMITATIONS.—Quantitative treatment limitations, including limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.
“(II) NONQUANTITATIVE TREATMENT LIMITATIONS.—Nonquantitative treatment limitations, including other limits on the access, scope, or duration of benefits for treatment under a plan or coverage not described in subclause (I), such as—
“(aa) medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
“(bb) for plans with multiple network tiers (such as preferred providers and participating providers), network tier design;
“(cc) standards for provider admission to participate in a network, including reimbursement rates;
“(dd) refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols);
“(ee) exclusions based on failure to complete a course of treatment; and
“(ff) restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.
“(ii) EXCLUSIONS.—The term ‘treatment limitation’ does not include any exclusions from coverage of items or services for which payment is not made under part A or part B or any statutory limitations on coverage applicable under such parts.”.
(2) ENFORCEMENT.—Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w–27(g)(1)) is amended—
(A) in subparagraph (J), by striking “or” after the semicolon;
(B) by redesignating subparagraph (K) as subparagraph (L);
(C) by inserting after subparagraph (J), the following new subparagraph:
“(K) fails to comply with mental health parity requirements under section 1852(o) or applicable implementing regulations or guidance; or”;
(D) in subparagraph (L), as redesignated by subparagraph (B), by striking “through (J)” and inserting “through (K)”; and
(E) in the flush matter following subparagraph (L), as so redesignated, by striking “subparagraphs (A) through (K)” and inserting “subparagraphs (A) through (L)”.
(b) Prescription Drug Plans.—Section 1860D–4 of the Social Security Act (42 U.S.C. 1395w–104) is amended by adding at the end the following new subsection:
“(c) Parity In Mental Health And Substance Use Disorder Benefits.—The provisions of section 1852(o) (relating to parity in mental health and substance use disorder benefits) shall apply to PDP sponsors offering prescription drug plans in the same manner in which such provisions apply with respect to Medicare Advantage organizations offering MA–PD plans.”.
(c) Regulations.—Not later than 18 months after the date of enactment of this Act, the Secretary of Health and Human Services shall issue regulations to carry out the amendments made by this section.
(d) Effective Date.—The amendments made by this section shall apply with respect to plan years beginning after the date that is 2 years after the date of enactment of this Act, regardless of whether regulations have been issued to carry out such amendments by such effective date.
(e) Implementation Funding.—For purposes of carrying out the provisions of, including the amendments made by, this section, there are appropriated, out of amounts in the Treasury not otherwise appropriated, to the Centers for Medicare & Medicaid Services Program Management Account, $10,000,000 for fiscal year 2024, which shall remain available until expended.