Pr ep ar ed f o r M e m b ers an d Com m i t t ees of C ong r e ss
This report provides a detailed history of mental health parity legislation, including a discussion
of bills introduced in each Congress, and accompanying legislative action, including hearings,
markups, and floor votes. The legislation is in response to concerns about the coverage of mental
health benefits in group health plans, which is often more restricted than the coverage of physical
illness.
Some advocates for people with mental illness strongly support legislation that would require full
parity, citing research that shows the cost-effectiveness of treating mental illnesses. On the other
hand, health plans and employers offering self-insured plans contend that parity will cause
significant increases in coverage cost. Generally, the term full parity is used in this report to mean
that the treatment limitations and financial requirements on mental health coverage are the same
as those for coverage of physical illnesses. Treatment limitations include restrictions on number
of visits or days of coverage, or other limits on duration and scope of treatment. Financial
requirements include deductibles, coinsurance, copayments, and other cost-sharing requirements,
as well as annual and lifetime limits on coverage.
Mental health parity legislation was first introduced in 1992, and the Mental Health Parity Act
(MHPA) of 1996 was the first federal parity law. The MHPA requires partial parity by mandating
only that annual and lifetime dollar limits in coverage for mental health treatment under group
health plans offering mental health coverage be no less than that for physical illnesses. It also
provides an exemption to employers with 50 or fewer employees. On June 17, 2008, the President
signed into law P.L. 110-245, which extends MHPA through the end of 2008. About half of the
states have passed laws requiring full parity for mental health coverage. Full parity legislation th th th
was first introduced in the 107 Congress and reintroduced in the 108 and 109 Congresses, but
failed to pass.
Expanded mental health parity legislation passed in the second session of the 110 th Congress, th
following a number of unsuccessful attempts. (P.L. 110-343.) In the first session of the 110
Congress, Senator Domenici introduced the Mental Health Parity Act of 2007 (S. 558) on
February 12, 2007. Unlike previous versions of parity legislation, this bill had the support of
insurance companies and employers. The Congressional Budget Office (CBO) scored S. 558 and
estimated that, if enacted, the bill would increase premiums by 0.4%. On September 18, 2007, the
Senate passed S. 558 with an amendment, by a voice vote. On March 9, 2007, Representative
Patrick Kennedy introduced similar legislation, the Paul Wellstone Mental Health and Addiction
Equity Act (H.R. 1424), which was referred to three House committees. On March 5, 2008, the
House passed H.R. 1424 by a roll call vote. (House Roll Call Vote 101: 268-148, March 5, 2008.)
In June 2008, the negotiators in the House and Senate reached a compromise on the bill language,
which was passed in the House and Senate as part of H.R. 1424 on October 3, 2008.
Introduc tion . 1
102 nd Congress (1991-1992). 2
Bills and Resolutions. 2
Congressional Hearings. 3
Roll Call Votes. 3
103 rd Congress (1993-1994). 3
Congressional Hearings. 3
Roll Call Votes. 4
104 th Congress (1995-1996). 4
Bills and Resolutions. 4
Congressional Hearings. 5
Roll Call Votes. 5
105 th Congress (1997-1998). 6
Bills and Resolutions. 6
Congressional Hearings. 6
Roll Call Votes. 6
106 th Congress (1999-2000). 6
Bills and Resolutions. 7
Congressional Hearings. 7
Roll Call Votes. 7
107 th Congress (2001-2002). 7
Bills and Resolutions. 8
Congressional Hearings. 8
Roll Call Votes. 9
108 th Congress (2003-2004). 9
Bills and Resolutions. 9
Congressional Hearings. 9
Roll Call Votes. 9
109 th Congress (2005-2006). 9
Bills and Resolutions. 10
Congressional Hearings. 10
Roll Call Votes. 10
110 th Congress (2007-2008). 10
Bills and Resolutions. 10
Congressional Hearings. 11
Roll Call Votes. 12 th
95 Congress. 13 th
96 Congress. 13 th
104 Congress. 13 th
106 Congress. 13 th
107 Congress. 13 th
108 Congress. 14 th
109 Congress. 14 th
110 Congress. 14
Figure 1. State Mental Health Parity Laws. 15
Table B-1. Comparison of FEHB and State Parity Laws. 17
Appendix A. Medicare Mental Health Legislation. 13
Appendix B. State Laws Mandating Parity for Mental Health Coverage. 15
Author Contact Information. 20
Private health insurers often provide less coverage of mental illnesses compared to other medical
conditions. Historically, health plans have imposed lower annual or lifetime dollar limits on
mental health coverage, limited treatment of mental health illnesses by covering fewer hospital
days and outpatient office visits, and increased cost sharing for mental health care by raising
deductibles and copayments. The lack of parity (i.e., equivalence) in insurance coverage in part
reflects insurers’ concerns that mental disorders are difficult to diagnose, and that mental health
care is expensive and often ineffective. However, the 1999 Surgeon General’s report on mental
health concluded that mental illnesses are largely biologically based disorders like many other
medical conditions. It found that effective treatments exist for most mental disorders.
In 1996, Congress enacted the Mental Health Parity Act (MHPA) to address concerns about the
more restrictive coverage of mental health benefits in employer-sponsored group health plans.
The MHPA, however, is limited in its scope. It does not compel insurers to provide mental health
coverage. For group plans that choose to offer mental health benefits, the MHPA requires parity
only for annual and lifetime dollar limits on coverage. Group plans may still impose more
restrictive treatment limitations and cost sharing requirements on their mental health coverage.
Congress recently extended the MHPA through December 31, 2008.
Full-parity legislation was first introduced in the 107 th Congress and reintroduced in the 108 th and th
109 Congresses, but it failed to pass despite bipartisan support from lawmakers. Under full
parity, a plan must use the same treatment limitations and financial requirements in its mental 1
health coverage as it does in its medical and surgical coverage. Passage of full-parity legislation
is a priority for groups that advocate on behalf of the mentally ill, but is opposed by employer and
health insurance organizations because of concerns that it will drive up costs.
In the first session of the 110 th Congress, Senator Domenici introduced the Mental Health Parity
Act of 2007 (S. 558) on February 12, 2007. This bill was approved by the Senate on September
18, 2007. Unlike previous versions of parity legislation, the bill had the support of insurance
companies and employers. The Congressional Budget Office (CBO) scored S. 558 and estimated
that, if enacted, the bill would increase premiums by 0.4%. Representative Patrick Kennedy
introduced full parity legislation, the Paul Wellstone Mental Health and Addiction Equity Act
(H.R. 1424), on March 7, 2007. H.R. 1424 passed the House by a roll call vote of 268-148 on
March 5, 2008. For a more detailed analysis of these bills and the issues surrounding mental
health parity, see CRS Report RL31657, Mental Health Parity: Federal and State Action and
Economic Impact, by Ramya Sundararaman and C. Stephen Redhead. In June 2008, the
negotiators in the House and Senate reached a compromise on the bill language. Further
negotiations were held to develop offsets that were to be used to pay for the $3.4 billion that CBO
estimated this legislation would cost over 10 years. The compromise bill language passed in the 2
House and Senate as part of H.R. 1424, and was signed into law on October 3, 2008. The final
bill also provided funds to rescue the U.S. financial system.
1 T r e a t m e nt lim ita tions inc l ude r e s t r i c tions on the num be r of v i s its o r da y s of c ove r a g e , or ot he r lim its on the dur a t i on
a nd s c ope of tr e a t m e nt. Fina nc ia l r e quir e m e nts inc l ude de duc ti ble s , c o ins u r a nc e , c o - p a y m e nts , a nd ot he r c o s t s h a r i n g
r e quir e m e nts , a s w e ll a s a nnua l a nd l i f e ti m e li m its on the tota l a m ount of c o v e r a g e .
2 P . L . 11 0- 3 4 3 .
This report provides a legislative history of mental health parity, to help inform any future nd
congressional debate on this issue. For each Congress, beginning with the 102 (1991-1992),
there is a brief narrative summarizing the legislative activity, followed by a list of bills and
resolutions, hearings (if any), and roll call votes (if any). Appendix A lists, by Congress, bills that
focus solely on Medicare mental health coverage. Appendix B includes a map and table that
summarize the state mental health parity laws.
Mental health parity legislation was first introduced in the Congress in 1992 by Senators
Domenici and Danforth (see below). That same year the Senate Appropriations Committee
instructed the National Advisory Mental Health Council to prepare a report on the cost of mental
health parity. The following language appeared in the committee report to accompany the 3
FY1993 Labor-HHS appropriations bill:
T h e Co m m ittee ap p r eciates t h e r e p o r t o f t h e Natio n a l A d v i so r y Men t al Heal th Co u n c i l
en titled , “ M e n tal I l l n es s i n Am er ica: A Ser i es o f P u b lic Hear i n g s ,” w h ich in cl u d es a sp ecial
recom m e n d ation on t h e n eed to prov ide cov e rag e f o r sev e r e l y m e n t al l y il l Am er ica n s u n d e r
n a tion a l h ealt h care ref o rm . T h e C o m m ittee requ es t s th at t h e C oun cil prepare a rep o r t o n t h e
cos t of cov e ring m e dical trea t m e n t f o r s e v e re m e n t al ill n e s s co m m e n s u r ate w i t h oth e r
illn e sses a n d an a sse ss m e n t of t h e eff i cac y of treat m e n t of sev e re m e n t a l ill n e s s . T h e
Co m m ittee f u r t h e r r e q u e s ts t h at th i s r e p o r t b e tr an s m itted to th e Co m m ittee p r io r to n e x t
y ear’s h eari n gs as a u t h ori zed u n d er s ect i o n 406(g ) of t h e Pu bl i c H eal t h S e r v i ce A c t .
The Council’s report was published in the October 1993 issue of the American Journal of
Psychiatry. The report concluded that with advances in the field of psychiatry, mental illnesses
are now treatable, and that treatment of mental illness is cost-effective. Those arguments continue
to be used by advocates for the mentally ill.
S. 2696 (Equitable Health Care for Severe Mental Illnesses Act of 1992). Introduced by Senators
Domenici and Danforth on May 12, 1992. S. 2696 stated that “persons with severe mental
illnesses must not be discriminated against in the health care system; and health care coverage .
must provide for the treatment of severe mental illnesses in a manner that is equitable and
commensurate with that provided for other major physical illnesses.” To be considered
nondiscriminatory and equitable, the bill mandated mental health coverage that “is not more
restrictive than coverage provided for other major physical illnesses, provides adequate financial
protection to the person requiring the medical treatment for a severe mental illness, and is
consistent with effective and common methods of controlling health care costs for other major
physical illnesses.”
H.Con.Res. 296. Introduced by Representative Mike Kopetski on March 19, 1992. Expressed the
sense of the Congress that equitable mental health benefits must be included in any health care
reform legislation passed by the Congress.
3 S.R e pt. 1 02- 39 7, p. 96.
S.Con.Res. 126. Introduced by Senator Shelby on June 24, 1992. Expressed the sense of the
Congress that equitable mental health care benefits must be included in any health care reform
legislation passed by the Congress.
No hearings were conducted.
No roll call votes were conducted.
Congressional lawmakers addressed mental health parity during the debate on the Clinton rd
Administration’s health care reform proposal in the 103 Congress. The Clinton plan (introduced
as H.R. 3600 and S. 1757) provided for limited coverage of mental illness as part of its benefit
package, but included a phase-in of full parity by January 1, 2001. The bills reported by the
Senate Committee on Labor and Human Resources (S. 2296) and the Senate Committee on
Finance (S. 2351) both included provisions for establishing full parity, as did legislation reported
by the House Committee on Education and Labor (H.R. 3600). Attempts to enact comprehensive
health care reform ended on the Senate floor in August 1994. The full House did not debate health
care reform legislation.
In 1993, Senator Domenici testified on discrimination in mental health coverage before the
Senate Committee on Labor and Human Resources.
Senate Committee on Labor and Human Resources, May 13, 1993, Coverage of Mental and
Addictive Disorders in Health Care Reform. Testimony by Tipper Gore (Chairperson, Mental
Health Working Group, President’s Health Care Reform Task Force), Senator Domenici, and
health insurance representatives. [S.Hrg. 103-211]. In addition, the following five hearings held
during the congressional debate on the Clinton health plan included testimony on mental health
coverage and parity.
House Committee on Ways and Means, October 26, 1993. Testimony by the American
Psychological Association. [Serial No. 103-90, pp. 245-294]
Senate Committee on Labor and Human Resources, November 8, 1993. Testimony by
Representative Mike Kopetski and mental health professionals. [S.Hrg. 103-216, Pt. 2, pp. 104-
House Committee on Energy and Commerce, December 8, 1993. Testimony by mental health
advocates and health insurance representatives. [Serial No. 103-91, pp. 232-286]
House Committee on Education and Labor, February 3, 1994. Testimony by the Bazelon Center
for Mental Health Law. [Serial No. 103-62, pp. 22-73]
Senate Committee on Labor and Human Resources, March 8, 1994. Testimony by former First
Ladies Betty Ford and Rosalynn Carter. [S.Hrg. 103-216, Pt. 4, pp. 562-581]
No roll call votes were conducted.
Senators Domenici and Wellstone reintroduced the Equitable Health Care for Severe Mental
Illnesses Act (S. 298) on January 31, 1995. Similar language was approved by the Senate on April
18, 1996, as an amendment to S. 1028, the Health Insurance Reform Act. The amendment was
later dropped in conference. The conferees also rejected a partial parity amendment offered by
Senators Domenici and Wellstone covering only annual and lifetime dollar limits. The legislation
was signed into law, without any mental health parity provisions, as the Health Insurance
Portability and Accountability Act (HIPAA, P.L. 104-191).
On August 2, 1996, Senators Domenici and Wellstone introduced the Mental Health Parity Act
(MHPA, S. 2031), which required parity only for annual and lifetime dollar limits. The bill, which
included an exemption for employers with 25 or fewer employees, did not mandate mental health
coverage. The parity provisions applied only to those group health plans that chose to provide
mental health coverage. On September 5, 1996, Senators Domenici and Wellstone offered the
MHPA as an amendment to the FY1997 VA-HUD appropriations bill (H.R. 3666). By voice vote,
the Senate approved a second degree amendment offered by Senator Gramm, which exempted
health plans from the MHPA parity requirement if the cost of compliance exceeded the original
cost of coverage by 1%. The Senate approved the Domenici-Wellstone amendment, as amended,
on a 82-15 vote. During conference, the House conferees agreed to the parity amendment. MHPA
became Title VII of the FY1997 VA-HUD appropriation bill, which was signed into law on
September 26, 1996 (P.L. 104-204). MHPA amended both the Employee Retirement Income 4 th
Security Act (ERISA) and the Public Health Service (PHS) Act. During the 105 Congress
(discussed below), the MHPA provisions were added to the Internal Revenue Code (IRC) by the
Taxpayer Relief Act of 1997. By amending all three federal statutes (i.e., ERISA, the PHS Act,
and the IRC), the MHPA standards apply to a broad range of group health plans, as well as state-
licensed health insurance organizations. More details on the parity legislation and related roll call th
votes in the 104 Congress are provided below.
S. 298 (Equitable Health Care for Severe Mental Illnesses Act of 1995). Introduced by Senators
Domenici and Wellstone on January 31, 1995. Required that “persons with severe mental
illnesses must not be discriminated against in the health care system, and health care coverage .
4 P . L . 10 4-2 0 4 , T itle V I I , c o dif i e d a t 29 U. S.C. 11 85a a nd 42 U.S.C. 30 0g g - 5.
must provide for the treatment of severe mental illnesses in a manner that is equitable and
commensurate with that provided for other major physical illnesses.”
S. 2031 (Mental Health Parity Act of 1996). Introduced by Senators Domenici and Wellstone on
August 2, 1996. Required parity for annual and lifetime dollar limits on coverage in group health
plans that offer mental health benefits.
H.R. 4045 (National Mental Health Parity Act of 1996). Introduced by Representative Pete Stark
on September 10, 1996. Amended the IRC to require group health plans to provide full parity for
coverage of all conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, 5
Fourth Edition (DSM-IV). Amended the Medicare statute to restructure the mental health
benefit.
H.R. 4058 (Mental Health Parity Act of 1996). Introduced by Representative Marge Roukema on
September 11, 1996. Same provisions as S. 2031, plus the 1% compliance cost exemption.
H.R. 4135 (Newborns and Mothers Health Protection and Mental Health Parity Implementation
Amendments of 1996). Introduced by Representatives Bill Thomas and Pete Stark, September 24,
1996. Amended the IRC to incorporate the MHPA provisions.
No hearings were conducted.
April 18, 1996. On a vote of 30-68 the Senate rejected an amendment by Senator Kassebaum to
table the Domenici parity amendment to S. 1028. The Domenici amendment was subsequently
adopted by voice vote.
September 5, 1996. The Senate voted 82-15 to adopt the Domenici parity amendment to the
FY1997 VA-HUD appropriations bill (H.R. 3666). Note: immediately prior to this vote the Senate
had voted 75-22 to table a second-degree amendment to the Domenici amendment offered by
Senator Brown.
August 1, 1996. On a vote of 198-228 the House rejected a motion by Representative Pete Stark
to recommit the conference report for H.R. 3103 (i.e., HIPAA) to the committee, with instructions
to the House managers to improve mental health coverage while minimizing the impact on the
cost or availability of insurance.
September 11, 1996. The House voted 392-17 to adopt a motion by Representative Louis Stokes
to instruct the House conferees for H.R. 3666 (i.e., FY1997 VA-HUD appropriations), among
other things, to agree to the Senate mental health parity provisions.
5 T h e D S M, pr od uc e d by the A m er ic a n P s y c hia t r i c A s s o c i a tion, is a c o m p r e he ns iv e sy s t em of dia g nos is f o r ps y c hia t r i c
c ondi tio ns . T h e f ourth a n d c u rre n t e d iti on w a s pub lis he d in 19 95 a nd is a v a ila ble a t http ://w w w .ps y ch.org / r e s e a r c h / dor/
ds m / inde x . c f m .
On June 24, 1997, during the Senate floor debate on the Balanced Budget Act of 1997 (P.L. 105-
33; August 5, 1997), Senators Wellstone and Domenici introduced an amendment requiring State
Childrens’ Health Insurance Plan (SCHIP) plans that offer mental health benefits to provide full-
parity coverage. The amendment was agreed to by voice vote, but later rejected in conference.
However, the conferees accepted language requiring all SCHIP plans and Medicaid managed care 6
plans to meet the requirements of the MHPA.
Section 1531(a)(4) of the Taxpayer Relief Act of 1997 (P.L. 105-34; August 5, 1997) added the 7
MHPA provisions to the Internal Revenue Code (IRC). Two parity bills were introduced in the
House (see below), but there was no further legislative activity nor any hearings on mental health th
parity during the 105 Congress.
H.R. 621 (National Mental Health Parity Act of 1997). Introduced by Representative Pete Stark th
on February 5, 1997. Same language as H.R. 4045 in the 104 Congress.
H.R. 3568 (Mental Health and Substance Abuse Parity Amendments of 1998). Introduced by
Representative Marge Roukema on March 26, 1998. Amended the MHPA provisions in ERISA,
the IRC and the PHS Act to require full parity for mental health and substance abuse benefits in
group health plans that offer such coverage.
No hearings were conducted.
No roll call votes were conducted.
Four mental health parity bills were introduced (or reintroduced) during the 106 th Congress, but
none saw any legislative action. In 1999, President Clinton directed the Office of Personnel
Management (OPM) to implement full parity for mental health benefits in health plans offered
under the Federal Employees Health Benefits Program (FEHBP). This required plans
participating in FEHBP to cover medically necessary treatment for all categories of mental illness
listed in the DSM-IV. The Senate Committee on Health, Education, Labor, and Pensions held a
parity hearing on May 18, 2000.
6 P . L . 10 5- 3 3 , Se c tions 4 7 0 4 ( a ) a n d 4 9 0 1 , c o dif i e d a t 4 2 U . S . C . 13 9 6u- 2( b) ( 8 ) a n d 4 2 U . S . C . 13 97c c ( f ) ( 2 ) ,
resp ect i v el y .
7 P . L. 1 0 5 - 34 , S ect i o n 15 31 ( a ) ( 4 ) , co d i f i ed at 26 U. S . C . 98 12 .
S. 796 (Mental Health Equitable Treatment Act of 1999). Introduced by Senators Domenici and
Wellstone on April 14, 1999. Amended the MHPA provisions in ERISA and the PHS Act to
require parity with respect to the number of inpatient days and outpatient visits covered for
mental illness, but to require full parity for a categorical list of severe biologically based mental
illnesses.
H.R. 1515 (Mental Health and Substance Abuse Parity Amendments of 1999). Introduced by th
Representative Marge Roukema on April 21, 1999. Same language as H.R. 3568 in the 105
Congress.
H.R. 2445 (Mental Health Parity Enhancement Act of 1999). Introduced by Representative
Carolyn Maloney on July 1, 1999. Amended the MHPA provisions in ERISA, the IRC and the
PHS Act to require parity with respect to treatment limitations.
H.R. 2593 (National Mental Health Parity Act of 1999). Introduced by Representative Pete Stark th
on July 22. 1999. Same language as H.R. 621 in the 105 Congress.
Senate Committee on Health, Education, Labor, and Pensions, May 18, 2000, Mental Health
Parity. Witnesses included Senator Wellstone, Government Accountability Office (Report
GAO/HEHS-00-95), and the National Institute of Mental Health. [S.Hrg. 106-582]
No roll call votes were conducted.
With MHPA due to sunset on September 30, 2001, Senators Domenici and Wellstone
reintroduced the Mental Health Equitable Treatment Act (S. 543) on March 15, 2001. S. 543
amended the MHPA provisions in ERISA and the PHS Act, requiring full parity for all DSM-IV
diagnoses. The Senate HELP Committee held a hearing on mental health parity on July 11, 2001,
at which Senator Wellstone testified. On August 1, 2001, the Committee approved unanimously a
substitute version of S. 543 that included compromise language protecting the ability of health
plans to use managed care techniques and raising the small-employer exemption from 25 to 50
workers (same as MHPA). On October 30, 2001, Senators Domenici and Wellstone offered S.
543, as reported, as an amendment (S.Amdt. 2020) to the FY2002 Labor-HHS appropriations bill
(H.R. 3061), which the Senate approved by voice vote.
The House version of H.R. 3061 did not include any parity language. On December 18, 2001, the
House conferees rejected on a party-line vote Representative Patrick Kennedy’s motion to accept
the Domenici-Wellstone mental health parity amendment. However, the conference approved a
motion by Representative Duke Cunningham to include language in the bill reauthorizing the
MHPA through December 31, 2002. Conferees added language to the conference report (H.Rept.
107-342; December 19, 2001) “strongly urging the committees of jurisdiction in the House and
Senate to convene early hearings and undertake swift consideration of legislation to extend and th
improve mental health parity protections during the second session of the 107 Congress.”
During 2002, both the House Committee on Education and the Workforce and the Committee on
Energy and Commerce held hearings on mental health parity, but there was no further action
taken on the three parity bills introduced in the House (see below). In two separate legislative
actions, Congress reauthorized the MHPA through December 31, 2003. Section 610 of the Job
Creation and Worker Assistance Act of 2002 (H.R. 3090, P.L. 107-147) amended the MHPA
provisions in the IRC, and the Mental Health Parity Reauthorization Act of 2002 (H.R. 5716, P.L.
107-313) reauthorized the MHPA provisions in ERISA and the PHS Act. H.R. 5716 was
introduced by Representative John Boehner on November 13, 2002, and approved without
objection by the full House on November 15, 2002. That same day the Senate received and
passed the measure by unanimous consent.
S. 543 (Mental Health Equitable Treatment Act of 2001). Introduced by Senators Domenici and
Wellstone on March 15, 2001. Senate HELP Committee hearing on July 11, 2001. Committee
markup, August 1, 2001, at which the committee approved a substitute version of the bill by a
vote of 21-0 (S.Rept. 107-61, September 6, 2001).
H.R. 162 (Mental Health and Substance Abuse Parity Amendments of 2001). Introduced by th
Representative Marge Roukema on January 3, 2001. Same language as H.R. 1515 in the 106
Congress.
H.R. 2992 (Mental Health Parity Enhancement Act of 2001). Introduced by Representative th
Carolyn Maloney on October 2, 2001. Same language as H.R. 2445 in the 106 Congress.
H.R. 4066 (Mental Health Equitable Treatment Act of 2002). Introduced by Representative
Marge Roukema on March 20, 2002. Same language as S. 543, as reported by committee.
Senate Committee on Health, Education, Labor, and Pensions, July 11, 2001, Achieving Parity for
Mental Health Treatment. Witnesses included the American Psychiatric Association, Magellan
Health Services, and the Office of Personnel Management. [S.Hrg. 107-184]
House Committee on Education and the Workforce, Subcommittee on Employer-Employee
Relations, March 13, 2002, Assessing Mental Health Parity: Implications for Patients and
Employers. Witnesses included Representatives Marge Roukema and Patrick Kennedy, the
American Managed Behavioral Healthcare Association, and the ERISA Industry Committee
(ERIC). [Serial No. 107-51]
House Committee on Energy and Commerce, Subcommittee on Health, July 23, 2002, Insurance
Coverage of Mental Health Benefits. Witnesses included the American Psychiatric Association,
the American Association of Health Plans, and the National Association of Manufacturers. [Serial
No. 107-118]
No roll call votes were conducted.
The 108 th Congress extended the MHPA through the end of 2005. First, the Mental Health Parity
Reauthorization Act of 2003 (S. 1929, P.L. 108-197) reauthorized the MHPA through December
31, 2004. The bill was introduced by Senator Gregg on November 21, 2003, approved in the
Senate by unanimous consent the same day, and passed the House without objection on
December 8, 2003. It amended the MHPA provisions in ERISA and the PHS Act, but not the IRC.
Secondly, Section 302 of the Working Families Tax Relief Act of 2004 (H.R. 1308, P.L. 108-311)
reauthorized the MHPA through December 31, 2005. P.L. 108-311 amended the MHPA
provisions in all three statutes.
S. 10 (Health Care Coverage Expansion and Quality Improvement Act of 2003). Introduced by
Senator Daschle on January 7, 2003. Title II incorporated the Mental Health Equitable Treatment th
Act (same language as S. 543, as reported by committee, in the 107 Congress).
H.R. 953/S. 486 (Senator Paul Wellstone Mental Health Equitable Treatment Act of 2003).
Introduced by Representatives Patrick Kennedy and Jim Ramstad and by Senators Domenici and th
Kennedy on February 27, 2003. Same language as S. 543, as reported by committee, in the 107
Congress.
S. 1832 (Senator Paul Wellstone Mental Health Equitable Treatment Act of 2003). Introduced by
Senator Daschle on November 6, 2003. Same language as S. 486.
Senate Committee on Health, Education, Labor, and Pensions, May 18, 2000, Mental Health
Parity. Witnesses included Senator Wellstone, Government Accountability Office (Report
GAO/HEHS-00-95), and the National Institute of Mental Health. [S.Hrg. 106-582]
No roll call votes were conducted.
The 109 th Congress further extended the MPHA through the end of 2007. In the first session of th
the 109 Congress, the Employee Retirement Preservation Act (H.R. 4579, P.L. 109-151)
extended the provisions requiring mental health parity in ERISA, the PHS Act, and the IRC
through 2006. H.R. 4579 passed the House by voice vote on December 17, 2005, and passed the
Senate by unanimous consent on December 22, 2005. In the second session, Section 115 of the
Tax Relief and Health Care Act of 2006 (H.R. 6111, P.L. 109-432) extended the MPHA
provisions in all three statutes through 2007.
H.R. 1402 (Paul Wellstone Mental Health Equitable Treatment Act of 2005). Reintroduced by
Representatives Patrick Kennedy and Jim Ramstad on March 17, 2005. No legislative action was
taken on this bill, and no corresponding legislation was introduced in the Senate.
No hearings were conducted.
No roll call votes were conducted.
The second session of the 110 th Congress passed full-parity legislation. 8 In the first session,
Senator Domenici introduced the Mental Health Parity Act of 2007 (S. 558). This bill would
amend ERISA and the PHS Act. Representative Patrick Kennedy introduced the Paul Wellstone
Mental Health and Addiction Equity Act (H.R. 1424), which would amend ERISA, the PHS Act,
and the IRC. Both bills saw legislative activity (see below) and provisions from both bills were
reflected in the final law. In addition, the House and Senate have each passed legislation (H.R.
3162, S. 1337) that would require parity for mental health coverage, under the State Children’s
Health Insurance Program (SCHIP). On June 17, 2008, Sec. 401 of the Heroes Earnings
Assistance and Relief Tax Act of 2008 (P.L. 110-245, H.R. 6081) passed a further extension of the
MHPA through the end of 2008.
S. 558 (Mental Health Parity Act of 2007). Introduced by Senator Domenici on February 12,
2007. The bill was referred to the Senate Health, Education, Labor, and Pensions Committee,
which approved the measure with an amendment on February 14, 2007 (S.Rept. 110-53). The bill
passed the full Senate, with an amendment, by voice vote on September 18, 2007. The Mental
Health Parity Act of 2007 was very similar to the Paul Wellstone Mental Health Equitable
Treatment Act of 2005.
H.R. 1424 (Paul Wellstone Mental Health and Addiction Equity Act). Introduced by
Representatives Kennedy and Ramstad on March 7, 2007. Unlike the Senate version of full parity
legislation, this bill required plans to cover all mental illnesses. This bill was referred to the
8 P . L . 11 0- 3 4 3 .
House Ways and Means, Energy and Commerce, and Education and Labor Committees. On July
18, 2007, the House Education and Labor Committee approved H.R. 1424, with an amendment.
The measure, as amended, was approved by the House Ways and Means Committee on
September 26, 2007, and by the House Energy and Commerce Committee on October 16, 2007
(H.Rept. 110-374). H.R. 1424 passed the House by a roll call vote on March 5, 2008.
In June 2008, House and Senate lawmakers reached compromise on mental health parity
provisions to be included in the final bill. They differed, however, on the offsets developed to pay
for the $3.4 billion that CBO estimated the bill to cost over 10 years. On September 23, 2008, the
House introduced and passed the compromise provisions as H.R. 6983, with deferred tax breaks 9
on worldwide income tax as the offset. The Senate did not take any action on this bill. On
September 29, 2008, the Senate passed the compromised mental health parity bill by including it 10
in H.R. 6049, which did not have a specific offset for mental health parity. The House did not
take any action on this bill. Finally, key negotiators in the Senate used H.R. 1424 (the original th
mental health parity legislation passed in the House in the 110 Congress) as the vehicle to pass
the compromised mental health parity legislation within the Emergency Economic Stabilization
Act of 2008. While this bill did not include a specific offset for mental health parity, the entire bill
was offset by taxing individuals on a current basis if such individuals receive deferred
compensation from a tax indifferent party.
S. 1337 (Children’s Mental Health Parity Act). Introduced by Senator Kerry on May 8, 2007. This
bill was referred to the Committee on Finance and was passed by the Senate on August 2, 2007.
The companion bill in the House (H.R. 3162) was introduced by Representative Dingell on July
24, 2007. It passed the House on August 1, 2007. These bills, if enacted, would amend Title XXI
of the Social Security Act to provide for equal coverage of mental health services under the State
Children’s Health Insurance Program.
House Ways and Means Health Subcommittee, March 27, 2007, Mental Health and Substance
Abuse Parity. Witnesses included Representative Kennedy, Mental Health America, Anna Westin
Foundation, Group Health Cooperative, George Washington University, and Constella Group
LLC.
House Energy and Commerce Health Subcommittee, June 15, 2007, Mental Health and Addiction
Equity. Witnesses included Representative Kennedy, Representative Ramstad, Blue Cross and
Blue Shield of Rhode Island, Marley Prunty-Lara, Howard H. Goldman, American Benefits
Council, and the ERISA Industry Committee.
House Education and Labor Health, Employment, Labor, and Pensions Subcommittee, July 10,
2007, Mental Health and Addiction Programs. Witnesses included Rosalyn Carter, David
Wellstone, the Wisconsin State Insurance Commissioner, Amy Smith, Milliman and Robertson,
National Retail Federation, and Groom Law Firm.
9 P a ul W e lls tone a nd P e te D o m e nic i Me nta l H e a lth P a r i ty a nd A ddic tion E q u ity A c t of 2008.
10 Ene r g y I m pr ov em e n t a nd Ex te ns ion A c t of 20 08.
February 7, 2008. On a vote of 384 to 23, the House passed an extension of the MHPA through
March 5, 2008. On a vote of 268 to 148, the House passed the Paul Wellstone Mental Health and
Addiction Equity Act of 2007 (H.R. 1424).
September 23, 2008. On a vote of 376-47, the House passed the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of 2008 (H.R. 6983).
September 23, 2008. On a vote of 93-2, the Senate passed the Energy Improvement and
Extension Act of 2008 (H.R. 6049).
October 1, 2008. On a vote of 74-25, the Senate passed the Emergency Economic Stabilization
Act of 2008 (H.R. 1424).
October 3, 2008. On a vote of 263-171, the House passed the Emergency Economic Stabilization
Act of 2008 (H.R. 1424).
This section lists bills that focus solely on Medicare mental health. None of these bills became
law.
H.R. 13460 (Mental Health Amendments of 1978). Introduced by Representative Claude Pepper
on July 13, 1978. Provided coverage for mental illness on the same basis as coverage for physical
illness under Medicare and provided coverage for certain psychologic services under the
supplementary medical insurance benefits program.
H.R. 640 (Mental Health Amendments of 1979). Introduced by Representative Claude Pepper on
January 15, 1979. Provided coverage for mental illness on the same basis as coverage for physical
illness under Medicare and provided coverage for certain psychologic services under the
supplementary medical insurance benefits program.
H.R. 1456 (Medicare Mental Health Improvement Act). Introduced by Representative Pete Stark
on April 6, 1995. Provided expanded coverage of mental health and substance abuse services
under Medicare.
S. 3233 (Medicare Mental Health Modernization Act of 2000). Introduced by Senator Wellstone
on October 25, 2000. Replaced the 50% coinsurance for outpatient psychiatric services with the
20% coinsurance required for all other Medicare part B services. Added community-based and
residential services to the Medicare mental health benefit package and expanded the number of
mental health professionals eligible to provide services through Medicare to include clinical
social workers and licensed professional mental health counselors.
H.R. 1522/S. 690 (Medicare Mental Health Modernization Act of 2001). Introduced by
Representative Pete Stark and Senator Wellstone on April 4, 2001. Replaced the 50% coinsurance
for outpatient psychiatric services with the 20% coinsurance required for all other Medicare part
B services. Added community-based and residential services to the Medicare mental health
benefit package and expanded the number of mental health professionals eligible to provide
services through Medicare to include clinical social workers and licensed professional mental
health counselors.
H.R. 1340/S. 646 (Medicare Mental Health Modernization Act of 2003). Introduced by
Representative Pete Stark and Senator Corzine on March 18, 2003. Replaced the 50%
coinsurance for outpatient psychiatric services with the 20% coinsurance required for all other
Medicare part B services. Added community-based and residential services to the Medicare
mental health benefit package and expanded the number of mental health professionals eligible to
provide services through Medicare to include clinical social workers and licensed professional
mental health counselors.
H.R. 2787/S. 853 (Medicare Mental Health Copayment Equity Act of 2003). Introduced by
Representative Ted Strickland on July 17, 2003, and by Senator Snowe on April 10, 2003.
Replaced the 50% coinsurance for outpatient psychiatric services with the 20% coinsurance
required for all other Medicare part B services.
H.R. 1946/S. 927 (Medicare Mental Health Modernization Act of 2005). Introduced by
Representative Pete Stark and Senator Corzine on April 27, 2005. Eliminates lifetime limit on
inpatient mental health services, provides for parity in treatment for outpatient mental health
services, coverage of intensive residential services under Medicare part A (Hospital Insurance)
and of intensive outpatient services under Medicare part B (Supplementary Medical Insurance);
excludes clinical social worker services from coverage under the Medicare skilled nursing facility
prospective payment system. Added coverage of marriage and family therapist services and
mental health counselor services under Medicare.
H.R. 1125/S. 1152 (Medicare Mental Health Copayment Equity Act of 2005). Introduced by
Representative Ted Strickland on March 3, 2005, and by Senator Snowe May 26, 2005. Provides
for a gradual reduction (from 50% to the standard 20%) by 2009 of copayment rates for
outpatient psychiatric services under the Medicare program.
H.R. 1571 (Seniors Access to Mental Health Act of 2007). Introduced by Representatives Murphy
and Napolitano on March 19, 2007. Phases out the difference in copayment rates for outpatient
psychiatric services, over five years. Referred to the Committee on Energy and Commerce, and to
the Committee on Ways and Means for consideration.
H.R. 1663 (Medicare Health Modernization Act of 2007). Introduced by Representatives Stark
and Kennedy on March 23, 2007. Eliminates the discriminatory co-payment for outpatient mental
health services (from 50% to the standard 20%). Eliminates the 190-day lifetime cap on inpatient
services in psychiatric hospitals.
H.R. 6331 (Medicare Improvement for Patients and Providers Act of 2008). Introduced by
Representative Rangel on June 20, 2008. Phases out the discriminatory co-payment for outpatient
mental health services (from 50% to the standard 20%) between 2010 and 2014. H.R. 6331
passed in the House (Roll No. 443) on June 24, 2008, and in the Senate by unanimous consent on
July 9, 2008. President Bush vetoed the bill on July 15, 2008. The veto was overridden in the
House and Senate on the same day, and H.R. 6331 became law (P.L. 110-275).
Forty-nine states and the District of Columbia (DC) have enacted legislation addressing mental
health coverage in some manner. Of those, 26 states have enacted full mental health parity laws.
State parity laws do not apply to federally funded public programs such as Medicaid, Medicare,
and the Veterans Administration, nor do they apply to self-insured health plans which are exempt
from state regulations under ERISA.
The following map summarizes the parity laws in each of the 50 states and DC. The 27 states
shaded in dark grey have laws requiring “full parity” for mental health. The seven states shaded
in light grey have “minimum mandated” laws, which require coverage for mental illness but do
not require coverage that is equal to that provided for other physical illnesses. The 15 states
shaded in black have “mandated offering” laws, which either require the insurer to offer the
option of a policy with coverage for mental illness, or require that if the insurer chooses to offer
mental health benefits, then they must be provided at the level specified in the law. The state that
is not shaded, Wyoming, has not enacted any parity legislation.
Figure 1. State Mental Health Parity Laws
Source: National Confere nce o n State Legislatures, Health Policy Tracking Service.
Table B-1 compares the state parity laws with FEHBP, and includes the following information.
First, it summarizes the type of parity law (full parity, minimum mandated, or mandated offering).
States that have full parity require annual and lifetime limits, treatment limitations, and
coinsurance and copayments for mental health coverage to be on par with that for other physical
illnesses. Second, the table compares the kinds of health insurance plans that are covered by the
different states’ parity laws. They could include health maintenance organizations (HMO), groups 11
plans, individual plans, and state employee plans. In four states, mental health parity laws apply
only to plans that cover state employees. Third, the table compares the types of mental illness
covered by the states’ parity laws. Some states require coverage for all illness listed in the DSM-
IV. Others require coverage for biologically based mental illness, severe mental illness, or serious 12
mental illness. Fourth, the table summarizes whether the financial and treatment limitations on
mental health coverage are required to be equal to that for other physical illnesses. Finally, the
table lists criteria under which certain employers and insurers may be exempt from the
requirements of the state parity laws. Fifth, the table lists whether each state explicitly or
implicitly allows medical management of the mental health benefits. Not all state statutes specify
all the requirements compared in the table. In instances where the criteria are unspecified, this
information is noted in the table.
11 HM Os a r e m a na ge d c a r e or g a niz a tions t h a t pr ov ide he a l t h i n s u r a n c e c o v e r a g e thr oug h hos p ita ls , d o c tor s , a n d ot he r
p r o v i d ers w i t h w h i c h t h e H M O has a co n t ract .
Gr o u p I n s u r a nc e : A g r oup is the m a s t e r ins u r e d a n d t h e ins u r a nc e c o m p a n y c ontr a c t s w ith the g r oup . I n s u r a nc e
cert i f i c at es, i ssu ed t o p a rt i c i p at i ng m e m b ers, act as t h ei r p o l i c y .
I n di vi du al I n s u r a nc e : In d i vi d u a l p l an s are t h o s e pu rch a sed b y an i n d i vi du al di rect l y w i t h t h e i n s u ran ce co m p an y .
S t at e E m pl oy ee P l an : P l an t h at co vers st at e e m p l o y ees.
12 B i ol og i c al : T h e r e a r e 13 DS M-I V dia g nose s c o m m only re fe rre d to a s bi olog ic a lly -ba s e d m e nta l illne sse s by m e nta l
he a lth p r ov ide r s a n d c o ns um e r or g a niz a tions . H o w e v e r , D S M- I V it s e lf doe s not dis ting u i s h be tw e e n biol og ic a lly - b a s e d
a nd o t he r ty pe s of m e nta l illne ss.
S e vere M e n t al Il l n ess : Di ff e r e n t sta t e s de f i ne this te rm slig htl y diff e r e n tly . Most inc l u d e , un de r this c a t e g or y ,
s c hiz ophr e n ia , s c hiz o a f f e c t i v e dis o r d e r , bip o la r m ood dis o r d e r , m a jor de pr e s s i o n , obs e s s i v e c o m puls i v e dis o r d e r , a n d
d e l u si on al di so r d er .
S eri ou s M e n t al Il l n ess : Me nta l illne sse s w h ic h a r e of su f f i c i e n t se v e rit y to re sult in su bsta ntia l i n te r f e r e nc e w ith the
a c tiv itie s of da il y liv ing . T h is inc l ude s s c hiz o phre n ia , s c hiz o a f f e c tiv e dis o rde r , a n d bip o la r m ood dis o rde r .
Table B-1. Comparison of FEHB and State Parity Laws
Plans a Illnesses Lifetime / Copayments & Treatment Limi ts b Medical c
State Type of Benefit Covered Covered Annual Limits Coinsura nce Inpatient Outpatient Exemptions Management
FEHB Full Parity 1,2 DSM-IV Equal Equal Equal Equal 2 Not Applicable
AR Full Parity 1,2 DSM-IV Equal Equal Equal Equal 1,2 Allowed
AL Mandated Off ering 1 DSM-IV Equal Equal Equal Equal 1 Allowed
AK Minimum Ma ndated 2 DSM-IV Equal Equal Equal Equal 1,2 Implied
AZ Mandated Off ering 1,2,3,4 DSM-IV Equal Unequal Unspecified Unspecified Implied
CA Full Parity 1,2,3 Severe Mental Illness Equal Equal Equal Equal Allowed
CO Full Parity 2 Bio logica l Equal Equal Equal Equal Not Specified
CT Full Parity 2,3 DSM-IV Equal Equal Equal Equal Allowed
i ki/CRS-RL33820 DE Full Parity 1,2,3,4 Serious Mental Illness Equal Equal Equal Equal Allowed
g/w
s .or DC Mandated Off ering 2,3 DSM-IV Equal Equal Equal Equal 2 Allowed
le ak FL Mandated Off ering 1,2 DSM-IV Unspecified Unspecified Unequal Unequal Not Specified
://wiki GA Mandated Off ering 2,3 DSM-IV Equal Equal Unequal Unspecified Not Specified
h ttp HI Full Parity 2,3 DSM-IV Equal Equal Equal Equal Allowed
ID Full Parity 4 Serious Mental Illness Equal Equal Equal Equal Not Specified
IL Full Parity 2 Serious Mental Illness Equal Equal Equal Equal 1 Allowed
IN Mandated Off ering 1,2,3,4 DSM-IV Equal Equal Equal Equal 2 Implied
IA Full Parity 2 Bio logica l Equal Equal Equal Equal 1 Allowed
KS Mandated Off ering 1,2,4 DSM-IV Unspecified Equal Unequal Unspecified Implied
KY Mandated Off ering 2 DSM-IV Equal Equal Equal Equal 1 Allowed
LA Mandated Off ering 1,2,4 DSM-IV Equal Equal Unequal Unequal 1,2 Implied
ME Full Parity 1,2 DSM-IV Equal Equal Equal Equal 1 Allowed
MD Full Parity 1,2,3 DSM-IV Equal Equal Equal Unequal Implied
Plans Illnesses Lifetime / Copayments & Treatment Limi ts Medical
State Type of Benefit Covered a Covered Annual Limits Coinsura nce Inpatient Outpatient Exemptions b Management c
MA Full Parity 1,2,3,4 Bio logica l Equal Equal Equal Equal 1 Implied
MI Minimum Ma ndated 1,2,3 DSM-IV Unspecified Equal Unequal Unequal 2 Not Specified
MN Full Parity 1 DSM-IV Equal Equal Equal Equal Implied
MS Mandated Off ering 2,3 DSM-IV Equal Equal Unequal Unequal 2 Allowed
MO Mandated Off ering 1,2,3 DSM-IV Unequal Unequal Unequal Unequal Implied
MT Full Parity 2,3 Severe Mental Illness Equal Equal Equal Equal Implied
NE Mandated Off ering 1,2 Serious Mental Illness Equal Equal Unequal Unequal 1,2 Allowed
NV Minimum Ma ndated 1,2,3 Severe Mental Illness Equal Unequal Equal Unspecified 1,2 Not specified
NH Full Parity 1,2,3,4 Bio logica l Equal Equal Equal Equal Implied
i ki/CRS-RL33820 NJ Full Parity 2,3,4 Bio logica l Equal Equal Equal Equal Implied
g/w
s .or NM Full Parity 2 Bio logica l Equal Equal Equal Equal Allowed
le ak NY Full Parity 1,2,3 Bio logica l Equal Equal Equal Equal 1,2 Allowed
://wiki NC Full Parity 2 DSM-IV Equal Equal Equal Equal Allowed
h ttp ND Minimum Ma ndated 4 DSM-IV Unequal Unspecified Unequal Unequal Allowed
OH Full Parity 2,3 Bio logica l Unspecified Unequal Equal Equal 2 Allowed
OK Full Parity 2 Severe Mental Illness Equal Equal Equal Equal 1,2 Allowed
OR Full Parity 1,2,3 DSM-IV Unequal Unequal Unequal Unequal Allowed
PA Minimum Ma ndated 1,2 Serious Mental Illness Equal Unequal Unequal Unspecified 1 Not Specified
RI Full Parity 1,2,3 Serious Mental Illness Equal Equal Equal Equal Allowed
SC Full Parity 4 DSM-IV Equal Equal Equal Equal Allowed
SD Full Parity 1,2,3 Bio logica l Equal Equal Equal Equal Implied
TN Minimum Ma ndated 2 DSM-IV Equal Equal Unequal Unequal 1,2 Allowed
Plans Illnesses Lifetime / Copayments & Treatment Limi ts Medical
State Type of Benefit Covered a Covered Annual Limits Coinsura nce Inpatient Outpatient Exemptions b Management c
TX Minimum Ma ndated 1,2,4 Serious Mental Illness Equal Equal Unequal Unspecified 1 Allowed
UT Mandated Off ering 1,2 DSM-IV Unequal Unequal Unspecified Unspecified Allowed
VT Full Parity 2,3,4 DSM-IV Equal Equal Equal Equal Allowed
VA Full Parity 2,3 Bio logica l Equal Equal Equal Equal Allowed
WA Full Parity 1,2 DSM-IV Equal Equal Equal Equal Allowed
WV Full Parity 4 DSM-IV Equal Unspecified Equal Equal 1,2 Allowed
WI Mandated Off ering 2 DSM-IV Unequal Unequal Unequal Unequal Implied
WY No parity law
Source: CRS.
Notes:
i ki/CRS-RL33820 a. Plans covered by s tate law:
g/w 1 = Health Mainte nance Orga nizations (HMOs)
s .or 2 = G roup Ins ura nce
le ak 3 = I ndividual Insura nce
4 = State E mployee Plans
://wiki b. Exem ptions:
h ttp 1 = Small employer: Em ployers with fewer t han a given n u m ber of employees, which ra nges f rom 10 to 51, may be e xempt from t he mental health pa rity
requirem ents.
2 = I ncrease s cost b y a given %: I f a health plan demonst rates t hat providing parity men tal health co verage raises t he p remium cost b y more tha n a given %, they ma y
be exe mpt f rom the mental h ealth parity req uirement s.
c. Medical Manageme nt:
Allowed : State law explicit ly per mits medical management or utili zation review.
Implied: State law refers to allowi ng health plans to “ma nage care” for mental health.
Not specified: No language in sta te parity law with rega rds to utilization review or medical management.
R a m y a S u n d arara m an C . Steph e n R e d h ead
An al y s t i n P u b lic Healt h Sp ecialist i n Healt h P o lic y
rs un dararam a n@ crs . l o c.g o v , 7- 7285 credh ead@ c rs .l oc.g ov , 7- 2261