Page:United States Statutes at Large Volume 122.djvu/3905

 12 2 STA T .38 82 PUBLIC LA W 11 0– 3 4 3 —O CT. 3 , 2008 bytheplan a dmi ni s t r at o r ( or the health ins u ran c e issuer o f ferin g such co v erage ) in accordance w ith regulations to any current or potential participant , beneficiary, or contracting pro - vider upon re q uest .T he 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 - NE T W O RKP RO VID ER S . —I nthecaseofaplan 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 bene- fits provided by out-of-networ k providers, the plan or coverage shall provide coverage for mental health or substance use dis- order 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 (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, e x cept as provided in subsection (a).’’; ( 3 ) in subsection (c)— ( A ) in paragraph ( 1 )( B )— (i) by inserting ‘‘(or 1 in the case of an employer residing in a S tate that permits small groups to include a single individual)’’ after ‘‘at least 2’’ the first place that such appears; and (ii) by striking ‘‘and who employs at least 2 employees on the first day of the plan year’’; and (B) by striking paragraph (2) and inserting the fol- lowing: ‘‘(2) C OST E X E M PTION.— ‘‘(A) IN G ENER AL .— W ith 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 deter- mined and certified under subparagraph (C)) by an amount that exceeds the applicable percentage described in subparagraph (B) of the actual total plan costs, the provi- sions of this section shall not apply to such plan (or cov- erage) 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.

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