HR 5028
110th CONGRESS
2d Session
H. R. 5028
To amend the Employee Retirement Income Security Act of 1974
and the Internal Revenue Code of 1986 to require that group health plans
provide coverage for pervasive developmental disorders such as autism.
IN THE HOUSE OF REPRESENTATIVES
January 16, 2008
Mr. WEXLER introduced the following bill; which was referred to the Committee
on Education and Labor, and in addition to the Committee on Ways and Means,
for a period to be subsequently determined by the Speaker, in each case
for consideration of such provisions as fall within the jurisdiction of
the committee concerned
A BILL
To amend the Employee Retirement Income Security Act of 1974
and the Internal Revenue Code of 1986 to require that group health plans
provide coverage for pervasive developmental disorders such as autism.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Fairness in Autism Treatment Act of 2007'.
SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) In General- Subpart B of part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended
by adding at the end the following new section:
`SEC. 714. PARITY FOR PERVASIVE DEVELOPMENTAL DISORDERS.
`(a) In General- A group health plan (and a health insurance issuer providing
health insurance coverage offered in connection with such a plan) that
provides both medical and surgical benefits shall provide coverage for
pervasive developmental disorders, including coverage for therapeutic,
respite, and rehabilitative care for participants or beneficiaries who
have not attained 22 years of age.
`(b) In-Network and Out-of-Network Standards-
`(1) IN GENERAL- In the case of a group health plan (or health insurance
coverage offered in connection with such a plan) that provides benefits
for pervasive developmental disorders, and that provides both in-network
benefits for such disorders and out-of-network benefits for such disorders,
the requirements of this section shall apply separately with respect
to benefits provided under the plan (or coverage) on an in-network basis
and benefits provided under the plan (or coverage) on an out-of-network
basis.
`(2) CLARIFICATION- Nothing in paragraph (1) shall be construed as requiring
that a group health plan (or health insurance coverage offered in connection
with such a plan) eliminate an out-of-network provider option from such
plan (or coverage) pursuant to the terms of the plan (or coverage).
`(1) ANNUAL OR LIFETIME DOLLAR LIMITATIONS- A group health plan (or
health insurance coverage offered in connection with such a plan) may
not impose any annual or lifetime dollar limitation on benefits for
pervasive developmental disorders unless such limitation applies to
all medical and surgical benefits and benefits for pervasive developmental
disorders under the plan (or coverage).
`(2) COST SHARING- A group health plan (or health insurance coverage
offered in connection with such a plan) may not impose a deductible,
coinsurance, or other cost-sharing with respect to the coverage of pervasive
developmental disorders under the plan (or coverage), which is greater
than the deductible, coinsurance, or other cost-sharing, as the case
may be, imposed with respect to medical and surgical benefits under
the plan (or coverage).
`(3) ELIGIBILITY TO ENROLL OR RENEW- A group health plan (or a health
insurance issuer providing health insurance coverage offered in connection
with such a plan) may not deny eligibility, or continued eligibility,
to enroll or to renew coverage under the term of the plan (or coverage),
solely for the purpose of avoiding the requirements of this section.
`(d) Notice Under Group Health Plan- The imposition of the requirements
of this section shall be treated as a material modification in the terms
of the plan described in the last sentence of section 102(a), for purposes
of assuring notice of such requirements under the plan; except that the
summary description required to be provided under the fourth sentence
of section 104(b)(1) with respect to such modification shall be provided
by not later than 60 days after the first day of the first plan year in
which such requirements apply.
`(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 the Internal Revenue Code of 1986 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) INCREASED COST EXEMPTION- This section shall not apply with respect
to a group health plan (or group health insurance coverage offered in
connection with a group health plan) if the application of this section
to such plan (or coverage) results in an increase in the cost under
the plan (or coverage) of at least 1 percent.
`(f) Pervasive Developmental Disorder Defined- For purposes of this section,
the term `pervasive developmental disorder' means any developmental disability
(as defined in section 102(8) of the Developmental Disabilities Assistance
and Bill of Rights Act of 2000 (42 U.S.C. 15002(8))).
`(g) Preemption, Relation to State Laws-
`(1) IN GENERAL- Nothing in this section shall be construed to preempt
any State law in effect with respect to health insurance coverage to
the extent the requirements of such law at least meet the requirements
of this section.
`(2) ERISA- Nothing in this section shall be construed to affect or
modify the provisions of section 514 with respect to group health plans.'.
(b) Conforming Amendments-
(1) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(2) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(c) Clerical Amendment- The table of contents in section 1 of such Act
is amended by inserting after the item relating to section 713 the following
new item:
`Sec. 714. Parity for pervasive developmental disorders.'.
(d) Effective Date- The amendments made by this section shall apply with
respect to plan years beginning on or after January 1, 2009.
SEC. 3. AMENDMENTS TO INTERNAL REVENUE CODE OF 1986.
(a) In General- Subchapter B of chapter 100 of the Internal Revenue Code
of 1986 (relating to group health plan requirements) is amended by adding
at the end the following new section:
`SEC. 9813. PARITY FOR PERVASIVE DEVELOPMENTAL DISORDERS.
`(a) In General- A group health plan that provides both medical and surgical
benefits shall provide coverage for pervasive developmental disorders,
including coverage for therapeutic, respite, and rehabilitative care for
participants or beneficiaries who have not attained 22 years of age.
`(b) In-Network and Out-of-Network Standards-
`(1) IN GENERAL- In the case of a group health plan that provides benefits
for pervasive developmental disorders, and that provides both in-network
benefits for such disorders and out-of-network benefits for such disorders,
the requirements of this section shall apply separately with respect
to benefits provided under the plan on an in-network basis and benefits
provided under the plan on an out-of-network basis.
`(2) CLARIFICATION- Nothing in paragraph (1) shall be construed as requiring
that a group health plan eliminate an out-of-network provider option
from such plan pursuant to the terms of the plan.
`(1) ANNUAL OR LIFETIME DOLLAR LIMITATIONS- A group health plan may
not impose any annual or lifetime dollar limitation on benefits for
pervasive developmental disorders unless such limitation applies to
all medical and surgical benefits and benefits for pervasive developmental
disorders provided under the plan.
`(2) COST SHARING- A group health plan may not impose a deductible,
coinsurance, or other cost-sharing with respect to the coverage of pervasive
developmental disorders under the plan, which is greater than the deductible,
coinsurance, or other cost-sharing, as the case may be, imposed with
respect to medical and surgical benefits under the plan.
`(3) ELIGIBILITY TO ENROLL OR RENEW- A group health plan may not deny
eligibility, or continued eligibility, to enroll or to renew coverage
under the term of the plan, solely for the purpose of avoiding the requirements
of this section.
`(1) SMALL EMPLOYER EXEMPTION-
`(A) IN GENERAL- This section shall not apply to any group health
plan for any plan year of a small employer.
`(B) SMALL EMPLOYER- For 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 50 employees on business days
during the preceding calendar year. For purposes 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
4980D(d)(2) shall apply.
`(2) INCREASED COST EXEMPTION- This section shall not apply with respect
to a group health plan if the application of this section to such plan
results in an increase in the cost under the plan of at least 1 percent.
`(e) Pervasive Developmental Disorder Defined- For purposes of this section,
the term `pervasive developmental disorder' means any developmental disability
(as defined in section 102(8) of the Developmental Disabilities Assistance
and Bill of Rights Act of 2000 (42 U.S.C. 15002(8)).'.
(b) Conforming Amendments- The table of sections for subchapter B of chapter
100 of such Code is amended by adding at the end the following new item:
`Sec. 9813. Parity for pervasive developmental disorders.'.
(c) Effective Date- The amendments made by this section shall apply with
respect to group health plans for plan years beginning on or after January
1, 2009.
END
