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AN EXAMINATION OF FEDERAL MENTAL HEALTH 

PARITY LAWS AND REGULATIONS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

SEPTEMBER 9, 2016 

Serial No. 114–167 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California7 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

DORIS O. MATSUI, California 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 2 

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 5 

Prepared statement .......................................................................................... 6 

Hon. Ben Ray Luja ́n, a Representative in Congress from the State of New 

Mexico, prepared statement ................................................................................ 57 

WITNESSES

Pamela Greenberg, MPP, President and CEO, Association for Behavioral 

Health and Wellness ............................................................................................ 8 

Prepared statement .......................................................................................... 11 

Michael A. Trangle, M.D., Senior Medical Director, Behavioral Health Division, HealthPartners Medical Group, Regions Hospital ................................... 20 

Prepared statement .......................................................................................... 23 

Matt Selig, Executive Director, Health Law Advocates, Inc. ............................... 32 

Prepared statement .......................................................................................... 35 

SUBMITTED MATERIAL

Letter of August 31, 2016, from Carmella Bocchino, Executive Vice President, 

et al., America’s Health Insurance Plans, to Cecilia Mun ̃ oz, Chair, White 

House Mental Health and Substance Use Disorder Parity Task Force, submitted by Mr. Pitts .............................................................................................. 59 

Letter of September 7, 2016, from Katrina Velasquez, Policy Director, Eating 

Disorders Coalition, to committee and subcommittee leadership, submitted 

by Mr. Pitts ........................................................................................................... 73 

Letter of September 8, 2016, from the American Association on Health and 

Disability, et al., to Members of Congress, submitted by Mr. Pitts ................. 77 

Statement of Patrick J. Kennedy, II, a Former Representative in Congress 

from the State of Rhode Island, submitted by Hon. Joseph P. Kennedy ........ 79 

Letter of December 16, 2015, from Rene ́e Binder, President, American Psychiatric Association, to Mr. Kennedy, submitted by Mr. Kennedy .................. 81 

Letter of January 28, 2016, from R. Jeffrey Goldsmith, President, American 

Society of Addiction Medicine, to Mr. Kennedy, submitted by Mr. Kennedy .. 83 

Letter of January 2016, from Kitty Westin, Member of the Board, et al., 

The Emily Program Foundation, to Mr. Kennedy, submitted by Mr. Kennedy ....................................................................................................................... 85 

Letter of August 31, 2016, from William C. Daroff, Senior Vice President 

for Public Policy and Director of the Washington Office, The Jewish Federation of North America, to the White House Mental Health and Substance 

Use Disorder Task Force, submitted by Mr. Kennedy ...................................... 86 

Letter of September 8, 2016, from Mary T. Giliberti, Chief Executive Officer, 

National Alliance on Mental Illness, to Mr. Pitts and Mr. Green, with 

NAMI report ‘‘A Long Road Ahead: Achieving True Parity in Mental Health 

and Substance Use Care,’’ submitted by Ms. Matsui ........................................ 88 

(1) 

AN EXAMINATION OF FEDERAL MENTAL 

HEALTH PARITY LAWS AND REGULATIONS 

FRIDAY, SEPTEMBER 9, 2016 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 9:00 a.m., in Room 

2322, Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Guthrie, Shimkus, Murphy, Burgess, Blackburn, Lance, Bucshon, Brooks, Collins, Green, 

Capps, Castor, Matsui, Luja ́n, Schrader, Kennedy, Ca ́ rdenas, and 

Pallone (ex officio). 

Staff present: Adam Buckalew, Professional Staff, Health; Rebecca Card, Assistant Press Secretary; Blair Ellis, Press Secretary; 

Jay Gulshen, Staff Assistant; Heidi Stirrup, Health Policy Coordinator; Jeff Carroll, Democratic Staff Director; Tiffany Guarascio, 

Democratic Deputy Staff Director and Chief Health Advisor; 

Samantha Satchell, Democratic Policy Analyst; Andrew Souvall, 

Democratic Director of Communications, Outreach and Member 

Services; Arielle Woronoff, Democratic Health Counsel; and C.J. 

Young, Democratic Press Secretary. 

Mr. PITTS. The subcommittee will come to order. 

Before we begin, I want to make a note that Members may be 

filtering in and out throughout the hearing. Unfortunately, with 

the condensed September session, there are a number of scheduling 

conflicts this morning. But we wanted to be sure to have this important hearing before Congress recessed at the end of the month. 

With that being said, the Chair recognizes himself for an opening 

statement. 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Today’s Health Subcommittee hearing will examine the Federal 

mental health parity laws and regulations. In 2008, Congress 

passed a bill requiring most group health plans to provide more 

generous coverage for treatment of mental illnesses, comparable to 

what is provided for physical illnesses. This Mental Health Parity 

and Addiction Equity Act, MHPAEA, which followed the Mental 

Health Parity Act of 1996, the MHPA, requires equivalence or a 

parity in coverage of mental and physical ailments. Parity means 

that insurers need to treat copayments, treatment limits, prior auVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
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thorization for mental health, substance use disorder the same way 

they treat for physical health care. 

The MHPAEA originally applied to group health plans and group 

health insurance coverage and then was amended by the Affordable 

Care Act to also apply to individual health insurance coverage as 

well as Medicaid benchmark and benchmark-equivalent plans. 

With more than 11 million Americans who suffer with severe 

mental illness, such as schizophrenia, bipolar disorder, major depression, this issue is vitally important for individual patients as 

well as families seeking appropriate care for their loved ones. 

Since there seems to be ongoing discussions or protections as envisioned in the mental health parity laws previously enacted, it is 

timely for this committee to consider ways to streamline the mental health parity system. 

Title VIII of the Helping Families in Mental Health Crisis Act, 

authored by committee member Tim Murphy of my home State, 

Pennsylvania, and Eddie Bernice Johnson of Texas, offers eight 

provisions concerning mental health parity, such as improved compliance guidance and disclosure support. 

Of particular interest to our Democratic committee members is 

a proposal by Representative Joe Kennedy of Massachusetts, H.R. 

4276, the Behavioral Health Coverage Transparency Act of 2015, 

and this bill offers one of the many approaches to modifying parity 

requirements. 

Today, we have three expert panelists who will provide testimony 

and answer questions on the strengths and challenges of mental 

health parity standards. And I look forward to the testimony today. 

[The prepared statement of Mr. Pitts follows:] 

PREPARED STATEMENT OF HON. JOSEPH R. PITTS

The subcommittee will come to order. 

The chairman will recognize himself for an opening statement. 

Today’s Health Subcommittee hearing will examine the Federal mental health 

parity laws and regulations. 

In 2008, Congress passed a bill requiring most group health plans to provide more 

generous coverage for treatment of mental illnesses, comparable to what is provided 

for physical illnesses. This Mental Health Parity and Addiction Equity Act 

(MHPAEA), which followed the Mental Health Parity Act of 1996 (MHPA), requires 

equivalence, or parity, in coverage of mental and physical ailments. 

Parity means that insurers need to treat copayments, treatment limits, and prior 

authorization for mental health and substance use disorder the same way they treat 

them for physical health care. 

The MHPAEA originally applied to group health plans and group health insurance coverage, and then was amended by the Affordable Care Act (ACA) to also 

apply to individual health insurance coverage as well as Medicaid benchmark and 

benchmark-equivalent plans. 

With more than 11 million Americans who suffer with severe mental illness such 

as schizophrenia, bipolar disorder, and major depression, this issue is vitally important for individual patients as well as families seeking appropriate care for their 

loved ones. 

Since there seems to be ongoing discussions on protections as envisioned in the 

mental health parity laws previously enacted, it is timely for this committee to consider ways to streamline the mental health parity system. 

Title VIII of the Helping Families in Mental Health Crisis Act, authored by committee member Tim Murphy of my home State, Pennsylvania, and Eddie Bernice 

Johnson of Texas, offers eight provisions concerning mental health parity, such as 

improved compliance guidance and disclosure support. 

Of particular interest to our Democrat committee members is a proposal by Rep. 

Joe Kennedy of Massachusetts, H.R. 4276, the Behavioral Health Coverage TransVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
3 

parency Act of 2015. This bill offers one of the many approaches to modifying parity 

requirements. 

Today, we have three expert panelists who will provide testimony and answer 

questions on the strengths and challenges of mental health parity standards. 

Mr. PITTS. I yield the balance of my time to the vice chair of the 

full committee, Mrs. Blackburn. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

To our witnesses today, we thank you. 

I want to thank the chairman for calling the hearing, and I want 

to thank all of my colleagues for the great work that we all did together as a team to pass that mental health reform package 

through the House, get it through the House in July. And I think 

it was significant that both sides came together on what I see as 

a very important issue today. 

As we talk with you all, I am going to want to highlight some 

items pertaining to the Zika virus. I do have tremendous concern 

about what we see happening here. 

Wall Street Journal had an article, and I would like to submit 

this for the record, Mr. Chairman. Researchers in the FDA now are 

mentioning that, with the Zika virus, we could potentially, probably will see an uptick in mental illness, Parkinson’s, diseases of 

that nature, dementia, et cetera. And we know that the virus is 

fast-spreading, fast-growing—I think 16,000 cases now in the U.S. 

and our territories. And I am quite concerned about the parallels 

between the virus and some of the mental health issues that we 

have. So I do want to highlight that. And, Mr. Chairman—— 

Mr. PITTS. Without objection, so ordered. 

Mrs. BLACKBURN. I appreciate that, and I yield back my time. 

Mr. PITTS. Is anyone seeking time? 

Mr. SHIMKUS. Mr. Chairman, just briefly. 

I want to welcome the panelists. And I go to a local healthcare 

provider in the mental health space, John Markley from 

Centerstone, Illinois. And I asked him these very same questions: 

What can be done to be helpful? And he listed just three things 

real quick: The Federal Government should use additional specific 

guidance to State regulators on plans on how to implement the 

Federal parity law, identify parity violations, and enforce the law 

in both public and private insurance. The Federal Government 

should issue additional guidance detailing the parity law transparency requirements and modeling for issuers an appropriate disclosure of coverage and plan design. And the Federal Government, 

Federal and State regulators should robustly enforce requirements 

of the Federal mental health, substance use disorder parity law 

prospectively during plan approval and retrospectively through 

complete investigations. And I will probably hear some of that from 

the testimony from our panelists. 

And I appreciate the time, Mr. Chairman, yield back. 

Mr. PITTS. The Chair thanks the gentleman. 

I also have a UC request. I ask unanimous consent to submit the 

following letters from America’s Health Insurance Plans to the 

4 

President’s task force; a letter from the Eating Disorders Coalition; 

a letter to Congress from 43 organizations representing providers, 

professionals, patients, family members, and consumers. 

Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. PITTS. The Chair now recognizes the ranking member of the 

subcommittee, Mr. Green, 5 minutes for an opening statement. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for having this important 

hearing. 

To our witnesses, thank each of you for taking your time out and 

being here this morning. 

For too long mental health and substance use care has been 

siloed from the rest of the healthcare system and stigmatized. Perhaps the biggest barrier to accessing care has been higher cost, 

lack of coverage for mental health, and substance use care on par 

with the physical health care. 

To begin to address this, Congress passed a Mental Health Parity Act in 1996. The law prohibited employer-sponsored group 

health plans from setting higher annual or lifetime dollar limits on 

mental health benefits than any other benefits. The Paul Wellstone 

and Pete Domenici Mental Health Parity and Addiction Equity Act 

in 2008 built on this first step and provided protections regarding 

equality of coverage for medical and surgical benefits and mental 

health and substance use benefits. This was further strengthened 

by the Affordable Care Act in 2010. 

While the progress has been made, there is much room for improvement. Since MHPAEA was enacted in 2008, insufficient enforcement, inconsistent compliance, spotty disclosure of medical 

management information and other implementation barriers to accessing mental health and substance use services with equivalency 

to physical health services has mooted the promise of the law for 

many. Today, we will be hearing with witnesses from the current 

state of parity laws and on-the-ground enforcement. Without strong 

enforcement of the parity law, millions of people continue to struggle to get health care they need. 

I look forward to learning more about this critical, important 

issue, and I thank you. And I would like to yield a minute and a 

half to my colleague from California, Doris Matsui. 

Ms. MATSUI. Thank you, Mr. Green. 

What we really want to do today is treat mental illness as a disease and afford the same prevention, early intervention, and treatment that we strive to have for physical illnesses. We are starting 

to make progress, but we have much more work to do. 

Mental health parity is an essential part of comprehensive reform. Parity is designed to ensure that insurance companies cover 

mental health benefits the same way they cover physical health 

benefits. Congress started this effort with a Mental Health Parity 

Act in 1996, and we have continued to build on it since then. We 

have made great strides with the Affordable Care Act by applying 

the concept of parity to more types of plans and more types of benefits and adding mental health and substance use disorder to the 

5 

list of essential health benefits. Yet we need to make sure that 

these laws are being applied and enforced consistently. 

We included provisions to strengthen the parity law and the 

mental health reform bill this committee worked hard to pass before the August recess. 

I also support the ideas my colleague, Representative Kennedy, 

has put forth to take these provisions a step further. I look forward 

to hearing from the witnesses today and what we can do moving 

forward to ensure that everyone has access to the treatments and 

services they need. 

I yield back to the ranking member. 

Mr. GREEN. Thank you. I thank my colleague for her work. 

The time has come now to actually enforce the mental health 

parity laws. Over the last 20 years, as both a State legislator and 

a Member of Congress, I have watched how we have tried to improve it, but it has not been successful. 

So, Mr. Chairman, I thank you for calling this hearing today, and 

again, hopefully, if not this session, then early next session, we can 

continue to work on making sure we provide the parity that mental 

health has with our physical illnesses in our insurance policies. 

Does anyone else want time from my side? 

I yield back my time. 

Mr. PITTS. The Chair thanks the gentleman and now recognizes 

the ranking member of the full committee, Mr. Pallone, 5 minutes 

for an opening statement. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. I just want to thank you, Mr. Chairman, and Mr. 

Green for this hearing on the state of mental health parity in 

America, because current mental health parity law requires that 

insurers treat mental health and substance use disorder care the 

same way they treat medical or physical care, and that includes copayments, treatment limits, and prior authorizations. 

Today, more than 41 million adults have some form of mental illness, but in 2014, less than half of them received mental health 

care. And more than 20 million people over the age of 12 have a 

substance use disorder, but only 2.6 million received treatment at 

a specialty facility in 2014. Perhaps this can be explained in part, 

because the majority of Americans do not know that there are mental health parity protections in current law. 

This Congress, we have had several important conversations on 

the challenges facing our mental health system. And we recently 

passed a bipartisan mental health bill in the House, and I am 

pleased that we are here today to continue that work by having a 

more indepth discussion on mental health parity. 

The last time we made major improvements to mental health 

parity laws was in 2010 when we passed the Affordable Care Act. 

The ACA expanded both parity protections and health insurance 

coverage, making early treatment and prevention services more accessible to millions of Americans. Under the ACA, all new individual and small group insurance plans are mandated to cover 

mental health and substance use disorder services as one of 10 esVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
6 

sential health benefits. In addition, the ACA expanded parity protections for mental health and substance use disorder services to 

individual health plans and certain Medicaid plans. So this essentially means that these plans must provide coverage for mental 

health and substance use disorder services at the same level as 

coverage for other medical services. 

So, today, I am interested in hearing from our witnesses about 

how our current parity laws are being implemented and enforced, 

because without proper enforcement, those laws will not have the 

impact we hoped for them to have. 

And, finally, I would like to thank Congressman Kennedy for his 

strong leadership on this topic and for requesting this hearing. He 

sponsored legislation this Congress that contains important parity 

provisions that were not included in our House-passed mental 

health bill. It is clear that we can and should be doing more to ensure that Americans are able to access necessary mental health 

and substance use disorder services, and I hope this hearing will 

shed some light on what steps we can take going forward. 

So I would like to yield the remainder of my time to Congressman Kennedy. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Thank you, Mr. Chairman. Good morning and thank you to our witnesses for joining us. We’re here this morning to have a discussion on the state of mental health 

parity in America. Current mental health parity law requires that insurers treat 

mental health and substance use disorder care the same way they treat medical or 

physical care. This includes copayments, treatment limits, and prior authorizations. 

Today, more than 41 million adults have some form of mental illness, but, in 

2014, less than half of them received mental health care. And more than 20 million 

people over the age of 12 have a substance use disorder, but only 2.6 million received treatment at a specialty facility in 2014. Perhaps this can be explained in 

part because a majority of Americans do not know that there are mental health parity protections in current law. 

This Congress, we’ve had several important conversations on the challenges facing 

our mental health system, and we recently passed a bipartisan mental health bill 

in the House. I’m pleased that we’re here today to continue that work by having 

a more in-depth discussion on mental health parity. 

The last time we made major improvements to mental health parity laws was in 

2010 when we passed the Affordable Care Act. The ACA expanded both parity protections and health insurance coverage, making early treatment and prevention 

services more accessible to millions of Americans. Under the ACA, all new individual and small group insurance plans are mandated to cover mental health and 

substance use disorder services as one of 10 Essential Health Benefits. In addition, 

the ACA expanded parity protections for mental health and substance use disorder 

services to individual health plans and certain Medicaid plans. This essentially 

means that these plans must provide coverage for mental health and substance use 

disorder services at the same level as coverage for other medical services. 

Today I’m interested in hearing from our witnesses about how our current parity 

laws are being implemented and enforced—because without proper enforcement, our 

parity laws will not have the impact we hope for them to have. 

Finally, I’d like to thank Congressman Joe Kennedy for his strong leadership on 

this topic and for requesting this hearing. He’s sponsored legislation this Congress 

that contains important parity provisions that were not included in our Housepassed bill. It’s clear that we can and should be doing more to ensure that Americans are able to access necessary mental health and substance use disorder services, 

and I hope this hearing will shed some light on what steps we can take going forward. 

I look forward to hearing from our witnesses today—and I’d like to yield the remainder of my time to Congressman Kennedy. 

7 

Mr. KENNEDY. I want to thank the ranking member and the 

ranking member of the subcommittee, Mr. Green. 

I also want to thank Chairman Upton and Chairman Pitts for allowing us to have this hearing today and for their leadership on 

mental health and continuing to make mental health parity a priority for this committee. 

I also want to thank Mr. Selig for his work and the work of 

Health Law Advocates, which has touched thousands of patients 

and families across Massachusetts. It is a privilege to have you 

representing our Commonwealth today, sir. 

And to all the tireless advocates out there who have helped inform our efforts in this committee, without your support, we 

wouldn’t be where we are today. I thank you. 

When the House passed this committee’s mental health bill in 

July, it was a needed step forward in our efforts to fix a deeply 

flawed system. But our work is far from over, because no matter 

how many providers we train, grant programs we fund or community health centers we expand, failure to ensure basic insurance 

coverage for those services means the vast majority of working and 

middle class families can’t afford them, and that is why I am grateful for today’s hearing. 

Parity, the simple idea that substance use disorder and heart 

disease should be treated the same is the law. That is not what 

this debate is, in fact, about. But without proper enforcement and 

transparency, the law is little more than empty words. It is meaningless to the patients and families who need and deserve the access the Mental Health Parity Act, the Mental Health Parity and 

Addiction Equity Act, and the Affordable Care Act were intended 

to guarantee. And that lack of enforcement and transparency has 

devastating consequences. 

I recently read a story of a mother whose son Matt lost his life 

after an insurance company continually refused to cover long-term 

treatment for his substance use disorder. She wrote that she, 

quote, ‘‘used to wish that Matt had cancer, at least he would have 

received timely, nonbiased treatment.’’ 

Beneath the heartbreaking stories and anecdotes are statistics to 

back them up. Claims for mental health care are denied at nearly 

twice the rate as claims for physical health. Twenty-four out of 25 

insurance companies in California charged higher copays or coinsurance for mental health care than physical health care, according 

to investigation by State regulators. Guided by those stories and 

statistics, I introduced the Behavioral Health Coverage Transparency Act to force insurers to disclose the rates and reasons for 

denials for mental health care while holding insurers accountable 

for any violations through random audits. Beyond those provisions, 

it would create a portal where patients not only lodge complaints 

but learn more about their coverage options. That lack of accessible 

information is a major roadblock to health care. My own legislative 

director, a health policy expert, spent over 2 unsuccessful hours on 

the phone with her insurance company last week trying to get the 

medical necessity documents she is entitled to by law and still has 

yet to receive them. 

Parity is a promise we made to millions of Americans who suffer 

from mental illness. It is not just a legislative technicality or reguVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
8 

latory minutia; it is their lifeline. We haven’t yet made good on 

that promise. We are allowing insurers to hide behind a curtain of 

proprietary information and a broad language of denial. Unless and 

until this committee becomes serious about ensuring parity as a 

lived reality for patients and the families who love them, meaningful mental health reform will remain out of reach. 

In this body, those reforms begin in this committee room, and I 

hope that my colleagues will join me in calling for parity to be included in any conference report that reaches the President’s desk. 

Thank you. I yield back. 

Mr. GUTHRIE [presiding]. Thank you. 

The gentleman yields back. 

All opening statements have been concluded, and all members 

have the opportunity to submit statements for the record. 

I would like to introduce the panel we have before us today. 

First, I will introduce all three. Then we will have their opening 

statements. Ms. Pamela Greenberg, president and CEO, Association for Behavioral Health and Wellness; we also have Dr. Michael 

A. Trangle, senior medical director, Behavioral Health Division, 

HealthPartners Medical Group; and Matt Selig, executive director, 

Health Law Advocates. 

Thank you for coming today, and you each have 5 minutes to 

summarize your testimony, and your written testimony will be 

placed in the record. If you notice the lights, you will get a yellow 

light when you get close, and then when the red light, it would be 

time to sum up if you haven’t concluded at that point. 

And I will begin with recognizing Ms. Greenberg for 5 minutes. 

STATEMENTS OF PAMELA GREENBERG, MPP, PRESIDENT AND 

CEO, ASSOCIATION FOR BEHAVIORAL HEALTH AND 

WELLNESS; MICHAEL A. TRANGLE M.D., SENIOR MEDICAL 

DIRECTOR, BEHAVIORAL HEALTH DIVISION, 

HEALTHPARTNERS MEDICAL GROUP, REGIONS HOSPITAL; 

AND MATT SELIG, EXECUTIVE DIRECTOR, HEALTH LAW ADVOCATES, INC. 

STATEMENT OF PAMELA GREENBERG 

Ms. GREENBERG. Good morning, Vice Chairman Guthrie, Ranking Member Green, and distinguished members of the subcommittee. Thank you for the opportunity to testify before you 

today. 

My name is Pamela Greenberg, and for the last 18 years, I have 

served as the president and CEO of the Association for Behavioral 

Health and Wellness. ABHW is an association of the Nation’s leading specialty behavioral health companies. These companies provide an array of behavioral health services to over 170 million people in both the public and private sectors. Since its inception in 

1994, ABHW has actively supported mental health and addiction 

parity. And we believe that it is important to diagnose and treat 

mental health and substance use disorders at an early stage. 

ABHW is an original member and at one point chair of the Coalition for Fairness in Mental Illness Coverage. In my testimony 

today, I will provide a brief overview of MHPAEA, discuss compliVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
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ance and enforcement, and discuss some next steps as we continue 

to move forward with parity implementation. 

MHPAEA, as members have already said, expands upon the 

Mental Health Parity Act of 1996 that created parity for annual 

and lifetime limits between mental health and physical health benefits. MHPAEA applies to plans with over 50 employees. It does not 

mandate coverage for mental health and substance use disorders. 

The law and regulations state that financial treatment and nonquantitative treatment limits can be no more restrictive than those 

on the physical side. Additionally, the law requires the disclosure 

of medical necessity criteria and the reason for denial. The law also 

provides that if out-of-network services are available on the physical health side, they must also be available on the mental health 

side. 

It is important to note that parity was not intended to be the 

panacea for all mental health and addiction issues. For example, 

parity does not address our workforce shortage issues nor does it 

look at the quality of care that is being provided. 

The Affordable Care Act extended MHPAEA to individual markets, small group, and qualified health plans. Parity also applies in 

Medicaid and TRICARE. 

Since MHPAEA’s passage in 2008, our member companies have 

had numerous meetings with the regulators to help us better understand and operationalize the regulations. Our member companies have teams of dozens of people from multiple departments 

working diligently to exchange information and perform the required analyses. 

The analyses are complex. For example, in order to complete the 

parity analysis, ABHW member companies review a variety of documents, including summary plan documents, medical necessity criteria, and medical management program descriptions. And then 

they document the underlying processes, strategies, evidentiary 

standards, and other factors considered by the plan. And then they 

review these findings with the organization’s legal team and recommend any needed changes. Our members have been audited for 

parity compliance at both State and Federal levels. 

The DOL and HHS have been enforcing MHPAEA through investigations and health plan audits. In its January 2016 report to 

Congress, the DOL reported that, since October 2010, they have 

conducted 1,515 MHPAEA investigations and cited 171 violations. 

HHS has also received complaints and, to date, has been able to 

avoid litigation by resolving the issues through voluntary changes 

by the health plans. Regulating agencies have also issued multiple 

sets of frequently asked questions and fact sheets. 

This year, President Obama established a White House Mental 

Health and Substance Use Disorder Parity Task Force that is going 

to—that is working to improve parity. I ask that our comment letter to the task force be included in the record. 

To say that parity is not being implemented and enforced is a 

misrepresentation. It is important to recognize the strides that 

have been made and work together to develop best practices to 

move forward. We have to make sure that we are not so rigid with 

our implementation of parity that we end up ignoring the difVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
10 

ferences that exist between behavioral and physical health and, as 

a result, compromise quality care. 

Further discussion is needed on the disclosure issue. Transparency and disclosure of information to consumers is important, 

but we also have to keep in mind the results of a new research 

paper that found that 86 percent of participants could not define 

deductible, copay, coinsurance, and out-of-pocket maximum in a 

multiple-choice questionnaire. Recent legislative attention in the 

area of disclosure has contributed to the issuance of additional 

guidance. What is missing from this discussion has been the volume and technical nature of these documents. There needs to be 

a more concise option for consumers to understand how their 

health plan has implemented parity without burying them with 

hundreds of documents. 

Some ideas to consider include the development of a document 

that a plan would use to explain how they have performed the parity analysis. Another idea is to provide examples that would include scenarios of questions a consumer might ask and then also 

the documents they may want to request to answer those questions. A third area that needs additional attention is education to 

all stakeholders as to what is and isn’t included in parity. HHS is 

working with States and the National Association of Insurance 

Commissioners. DOL has issued a compliance assistance guide and 

the check sheet to assist employers, and SAMHSA has information 

on their Web site. 

If I could just finish up. Our members are faced with disparate 

and sometimes incorrect interpretations by State agencies enforcing the Federal law, and we would like to see more consistent enforcement. We also support the release of the identified information 

that are found by the regulators. 

And, finally, if I could just bring two issues to your attention, 

and those are the disclosure of substance use records related to 42 

CFR in part 2 and meaningful use incentives for behavioral health 

providers. We hope that the committee considers those issues at a 

later date. 

Thank you for the opportunity to testify today, and I look forward to ongoing discussions as we move forward. 

[The prepared statement of Ms. Greenberg follows:] 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

Mr. GUTHRIE. Thank you for testifying. 

Dr. Trangle, you are recognized for 5 minutes. 

STATEMENT OF MICHAEL A. TRANGLE 

Dr. TRANGLE. Thank you, Vice Chairman Guthrie, Ranking 

Member Green, and all the committee members. 

I am Michael Trangle. I am a practicing psychiatrist and also a 

senior medical director for HealthPartners Medical Group, one of 

our hospitals, and have been really actively involved in kind of efforts we have been doing to make things better. I am very involved 

in quality improvement, leading initiatives to improve depression 

outcomes outpatient, reduce readmissions for people coming from 

psych units, trying to lengthen the lifespan of folks with serious 

mental illnesses in our State, and just work hard on that. 

I am from an integrated organization where there is a health 

plan medical group of about 1,800 docs, hospitals. The health plan 

covers 1.36 million lives. We have got 22,500 employees. I know 

that we are all working hard to try to produce parity, both clinicians like me and administrators who know the details of the law 

and the policy in a way that I don’t, to try to really make sure we 

understand and are fully implementing it. 

I want to talk about some of the efforts we are doing in the real 

world at the ground level to try to make things better. One initiative that we have been very successful with is, with our public 

radio station and NAMI and other organizations, doing a campaign 

to reduce stigma called Make It OK, which actually helps access. 

There is so much shame involved and avoidance of getting involved 

in treatment that, if you can start conversations, people would be 

willing to either listen to their primary care doc or bring it up and 

get going. I know that, for our members, we measure closely and 

look for improvements. We are at a 96 percent member satisfaction 

of either very satisfied or satisfied for access to behavioral health 

resources in our system. 

We have come up with ways that we have offered—we think it 

is so good to our employees as well as all of our patients, whether 

they have our health plan or not and are health plan members— 

where they can go online on the Internet and participate in a cognitive behavioral therapy treatment program at their leisure, at 

their own pace, to improve depression and anxiety care. 

We have created an algorithm, based upon claims, to look at who 

is at high risk to not do well in the next 6 months. And I can give 

you an example of one of my patients who is a 44-year-old 

woman—married, three kids, lives in the burbs—who started seeing me as an outpatient for depression and anxiety and, despite my 

best efforts, wasn’t getting better. Then I realized she was probably 

abusing substances. And then when I talked to her, she wasn’t interested or willing to do treatment. She got worse. She ended up 

getting drunk, passed out while smoking in bed. Her house burned 

down. Thankfully, her kids and husband got out safely, but she had 

between 20 and 30 percent burns. She got hospitalized in a burn 

unit in a hospital that is not integrated with our system but part 

of our health plan network, was there for about 3 weeks, came out, 

and still was even worse than before. She was still depressed, anxVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
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ious. She had started abusing opiates, because she had pain now, 

as well as drinking. 

And we had a healthcare coordinator that was working with this 

person because of our algorithm. And her job is to reach out and 

talk to all the various places and people involved in her care. She 

reached out to the hospital and found out that the patient was actively suicidal there and had been civilly committed and was under 

court order to undergo and participate in psychiatric care, supposedly under my direction. She had not filled out a release of information, lied to me about it, but this care coordinator discovered 

this. And then all of a sudden, I could have a real honest discussion with her. And we got her into a dual-diagnosis CD treatment 

facility. And it is about 2 years later now and she is still off opiates 

and alcohol and not really depressed, still struggles with anxiety, 

but her life is turned around. And it was all because of this kind 

of extraordinary care coordination that spanned different levels of 

care and systems of care that probably saved her life. 

I agree with the workforce shortage. You know, we find that we 

are doing a lot of things to try and put psychiatrists and therapists 

in our primary care clinics. And there is a shortage of health psychologists. There is a shortage of psychiatrists. We have been taking efforts, in partnership with NAMI, to do extra training, to get 

physician’s assistants and nurse practitioners and clinical nurse 

specialists to increase our pool of prescribers. 

We are working hard to improve the flow of psychiatric patients. 

We have patients accumulating in the ED waiting to get into psych 

units, and people on psych units who can’t get out waiting to get 

into group homes and residential treatment centers. And we need 

to partner with counties and States who are responsible for those 

things, and they have budget shortages, and there are not enough. 

And I see I am going to run out of time. But one other thing that 

we have been trying to work on, but it is hard, is kind of payment 

reform so that we can flow our money to pay for outcomes and can 

then afford to have care managers in our clinics reaching out to patients between visits, reaching out to make sure, ‘‘It has been so 

long, you haven’t rechecked, how are you doing with your depression,’’ and making sure they come in and that they are getting into 

remission. And it requires partnerships in ways that I don’t think 

is usually talked about. That is viewed as the public sector. We are 

viewed as the private sector. And we have got to work together. 

And when we do that, we can sort of get patients out of the hospital sooner into group homes and then our EDs. We are overflowing our safe space or locked space for psych patients. We can 

get them into the inpatient unit. 

And a lot of what we are doing really involves kind of taking disparate partners and agreeing to a vision and then trying to work 

together, but it is very hard because the funding streams are not 

braided. I see I am going to be out of time pretty shortly. 

Mr. GUTHRIE. If you could just summarize. I mean, I will be a 

little lenient, but if you could just summarize. 

Dr. TRANGLE. You know, in a lot of ways, there are also new 

models of care where we are trying to sort of really truly integrate 

behavioral health resources with health plan resources, both delivery system—and this care coordination is another way of doing 

22 

this. We have programs where, if I have my patient and they don’t 

get their refills for their antipsychotics, I will hear about it because 

of the health plan feeding that data to me. The patient hears about 

it. We can reach out and try to capture them so they don’t get psychotic and really struggle. We do the same thing with depressed 

patients. And it really helps a lot. 

We have initiatives where we have got people like me going or 

telemedicine going to primary care clinics. Primary care docs will 

talk about their depressed patients and their issues and their 

struggles. I will give advice. And for 2 hours a week, I can sort of 

leverage what primary care is doing for about 100 patients, so leverage the shortage of psychiatrists. 

[The prepared statement of Dr. Trangle follows:] 

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25 

26 

27 

28 

29 

30 

31 

32 

Mr. GUTHRIE. We also have the chance to reiterate some of this 

during our question-and-answer period. We appreciate it very 

much. Thank you. Thank you for that testimony. It is very informative. 

Mr. Selig, you are recognized for 5 minutes. 

STATEMENT OF MATT SELIG 

Mr. SELIG. Vice Chairman Guthrie, Ranking Member Green and 

members of the committee, thank you very much for the opportunity to appear before you today as you examine the parity law 

and regulations. I am grateful that you have convened this hearing. 

My name is Matt Selig, and I am the executive director of Health 

Law Advocates. HLA is a nonprofit public-interest law firm with a 

mission to improve access to health care for low-income Massachusetts residents. We provide pro bono legal assistance to low-income 

clients who have been denied needed health care. 

HLA has made mental health and substance use disorders parity 

a priority for more than a decade. We try to improve access to mental health and substance use disorders care by making the protections of the parity laws, both Federal and State, a reality for those 

we represent. HLA represents approximately 70 clients each year 

who have been denied coverage for treatment of mental illness or 

substance use disorder. This work gives us an up-close look at the 

problems consumers have when trying to access treatment. We also 

see how current parity laws and regulations are implemented and 

enforced. HLA works very closely with other advocates across the 

country with a strong interest in parity. As a result, we have a 

broader perspective on the insurance problems people face when 

they need treatment and how the parity laws are or are not addressing the problems. 

While we and others believe there is much more important work 

still needed to achieve true parity, I want to express HLA’s appreciation to you and as well as State legislators and regulators across 

the country who have made significant gains achieving parity already. We are particularly gratified that parity has been very much 

a bipartisan issue in Congress, and that has been true in Massachusetts as well. 

In Health Law Advocates’ experience with clients, individuals 

have more difficulty accessing mental health and substance use 

care than other types of care because of barriers created by many 

insurers. Our assessment corresponds with the findings of the National Alliance on Mental Illness report issued last year, which 

found that twice as many families reported that a member of their 

family was denied coverage for mental health care as for general 

medical care. 

Our lawyers have identified certain types of mental health and 

substance use treatment that are particularly susceptible to coverage denials. I will mention some, but this is not meant to be exhaustive: residential treatment for substance use disorders, eating 

disorders, and other severe mental illness; applied behavioral analysis for autism spectrum disorder; medication-assisted treatment; 

and outpatient psychotherapy more than once per week. 

HLA represents clients of all ages, but we devote particular resources to helping children access mental health and substance use 

33 

disorder care. Over the years, we have seen families struggle to obtain coverage for kids, especially for services such as neuropsychological evaluations, wraparound community-based care, autism services, and stepdown care from acute treatment. 

In our work, we have witnessed many different ways insurance 

practices frustrate treatment for our clients that appear to run 

counter to the parity laws. For example, we have seen repeated 

early terminations of coverage for residential substance use treatment, regardless of the severity of our clients’ symptoms; doctors 

being required to titrate medication-assisted treatment as a condition of coverage, even when mandatory titration is not the standard 

of care; treatment providers subject to onerous requirements to justify care; and termination of services arbitrarily based on age or alleged lack of parental participation. 

These examples involve clients who were fortunate enough to 

have at least connected with a provider. We also represent clients 

of all ages but particularly children who have great difficulty finding a qualified and appropriate provider in their insurer’s network. 

In closing, I wish to offer a few recommendations to improve on 

current parity laws and their implementation. We strongly support 

H.R. 4276, Congressman Kennedy’s Behavioral Health Coverage 

Transparency Act. There is no question that we need greater disclosure of information by insurers. Detailed information about how 

plans ensure that mental health and substance use disorder claims 

are treated equitably and the standards utilized to evaluate the 

medical necessity of treatment should be made public and written 

in language consumers can understand. 

There should also be greater enforcement, including enhanced 

penalties of requirements to provide detailed information to members about the basis for coverage denials and comparative information on medical management of physical conditions. When HLA requests this information on behalf of our clients, we rarely receive 

it. This prevents us from determining whether our clients’ parity 

rights have been violated. An explicit private right of action in the 

parity law would also allow consumers to enforce this right themselves. 

Consumers should also have access to an easy-to-use process for 

filing complaints when their right to equitable mental health and 

substance use disorder coverage has been violated. This would help 

consumers access the treatment they need and identify trends in 

noncompliance. The complaint process and consumers’ rights under 

the parity law should be broadly promoted by Government agencies 

to increase understanding among consumers. 

The Federal Government should also assist carriers’ compliance 

by publicizing and continually updating its adjudication of parity 

complaints to create an administrative common law for what constitutes a violation of the parity law. Neither insurers nor their 

members should have to guess what treatment limitation practices 

are illegal. 

Finally, we recommend that Federal and State agencies conduct 

random audits of health plans to ensure parity compliance. These 

inquiries and other reforms will serve as a check on self-reporting 

by plans and identify problem areas where Federal or State enforcement is needed—more enforcement is needed. That targeted 

34 

enforcement will ensure that parity is not only the law of the land 

but a reality for people suffering with mental illness and addiction. 

Thank you again very much for the chance to testify. 

[The prepared statement of Mr. Selig follows:] 

35 

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37 

38 

39 

40 

Mr. GUTHRIE. Thank you very much. 

I want to thank each witness for your testimony, and I will begin 

the questioning and recognize myself for 5 minutes for that purpose. 

As Chairman Pitts discussed during his opening remarks, there 

have been continued discussions on the safeguards envisioned in 

previously enacted mental health parity laws. 

Ms. Greenberg, one of the most recent documents ABHW published is a letter in response to the President’s task force. You urge 

the administration’s working group to engage with stakeholders on 

clinical differences, additional tools for States, release of the identified information, disclosure clarifying guidance and parity and confidentiality rules. 

I would like to focus on the clinical differences in disclosure and 

confidentiality rules. In this letter, you write, and I quote: ‘‘Parity 

is important, but so is quality. We have to make sure that we are 

not so rigid with our implementation of parity that we end up compromising on quality care of consumers,’’ unquote. 

Please help me better understand how clinical autonomy to 

achieve improved quality outcomes in caring for patients with mental health and substance use disorders can be impeded by burdensome or, better yet, one-size-fits-all regulations. 

Ms. GREENBERG. Sure. Thank you, Congressman, for that question. I think that our concern as we have moved forward with parity implementation is we have behavioral health and we have medical. And there are some things that are more clear-cut, like the copayments and the coinsurance and things like that. But then there 

are other things about the treatment that is needed or when you 

check in with a provider to see how the treatment is going. And 

those are things that differ based on illness, and they are not so 

cookie-cutter that you say, oh, exactly what you are doing on the 

medical side should be the same thing that is done on the behavioral health side. 

And we would just like to see some flexibility within the parameters of clinical guidelines. So it wouldn’t just be because we say 

we should do it this way, then it is OK, but the clinical guidelines 

may justify a difference in some areas on behavioral health. And 

that language was included in the initial interim final rule and 

then was deleted in the final rule. And so I think just recognizing 

that there are some differences that do exist and, when clinically 

appropriate, those should be allowed. 

Mr. GUTHRIE. Dr. Trangle, as a medical director, would you like 

to comment on that? 

Dr. TRANGLE. You know, I am not a policy guy. I am still seeing 

patients, and I do a lot of quality stuff. So I can’t comment on the 

details of the law. But I know that, clinically, all the time we are 

trying to improve talking to primary care docs, seeing their lab results, making sure they can see what we are doing. And in some 

sense, one of the things mentioned in the prelude had to do with 

chemical dependency. And we are struggling in our system with 

ED docs not seeing what meds or what is going on in CD treatment 

parts of our facility or what is going on in outpatient clinics and 

overmedicating people because we are not sharing some of that 

41 

data with each other. It is just really important to be able to talk 

together. 

It is an interesting place where stigma plays out. We have primary care docs that, in some sense, will kind of be afraid to talk 

about somebodyis depressed, you know, and shy away from it. But 

if they can see that we have talked about it, because we have a 

shared electronic medical record, they know it is OK, all of a sudden they can help us follow up and they can help us measure are 

they getting better or not. 

Mr. GUTHRIE. OK. Thank you. 

Let me get to my next question. 

Ms. Greenberg, you note that certain transparency and disclosure efforts may be well-intentioned but inadvertently overwhelm 

patients with thousands of pages of documentation, but other advocates have asked for even more access to benefits details. Would 

you please share a more efficient and effective way to help patients 

better understand parity, fairness? 

Ms. GREENBERG. Sure. The documentation that is available to 

patients or should be made available to patients includes a lot of 

information that health plans are using, either their analyses or 

the documents that they had to look at to get to what parity should 

include. 

And while those documents are available, we would also like to 

see some type of summary of the analysis instead of—our concern 

is that if we hand the patient a box or two of documents, that will 

overwhelm them. And, also, they are very technical, and it will be 

a little bit difficult to go through. So if we can talk about a uniform 

analyses that people would hand out first to explain to patients 

how parity was determined and then kind of go from there as more 

documents are needed and/or provide guidance to patients as to 

what documents are appropriate to ask for for their situation—not 

that they couldn’t have more but that at least at first they are getting just the documents that they need. 

Mr. GUTHRIE. OK. You, also, in the coordination that Dr. Trangle 

was talking about—our committee is really looking at coordination. 

We know that that is important. But in regard to substance use 

disorders, you comment that multiple signed patient authorizations 

are necessary to achieve true coordination. How does this limit 

quality of care? 

And then, Mr. Selig, would you comment on the fact that there 

are so many multiple signed documentation, is that a wall that the 

Federal Government should try to remove? 

Actually, I am out of time. I don’t want to go because we are kind 

of against votes. 

Mr. SELIG. If you could clarify which signed documentations you 

are referring to. 

Mr. GUTHRIE. Well, you know what, if I get into that, I am going 

to really get into that. I will put that in the record. We will give 

you a question for the record. Otherwise, it is going to take longer. 

We are running against—votes are going to come sometime midmorning, I understand. 

That concludes my questions. 

I will recognize the ranking member, Mr. Green, 5 minutes for 

questions. 

42 

Mr. GREEN. Thank you, Mr. Chairman, 

Millions of Americans, as many as one in five, have a mental illness. One in 10 Americans will have a substance disorder in their 

lifetime. And 75 percent of them will not seek treatment. The lives 

of these individuals and their families and their communities will 

be significantly changed for the better with access to the treatment 

they need. 

Congress did our part. We passed a parity law requiring health 

plans and Medicaid and Medicare and the private market to cover 

mental health and substance use treatment to the same extent as 

they do medical and surgical services. We passed the Affordable 

Care Act, which significantly expanded access to health coverage. 

However, without strong enforcement of the parity law, millions 

of people continue to struggle to get the health care they need. 

Mr. Selig, as a legal advocate, you are well aware of the importance of strong parity implementation and enforcement. I am sure 

you know how complicated and confusing insurance benefits can be 

and how hard it is to fight with an insurance company to get coverage for the benefits you need, especially when you are sick and 

need it the most. 

My first question is, how hard is it for consumers to get the information they need in order to figure out whether their insurer is 

meeting the requirements of parity? 

Mr. SELIG. Well, it can be very difficult, Mr. Green. As I mentioned in my statement, when we are working with consumers who 

have been denied coverage and they try to request information 

from their plan explaining why the service has been denied and 

providing the backup documentation comparing the medical management techniques for mental health and physical health, it is 

documents that really are rarely provided. And I recall Mr. Kennedy mentioning a member of his staff having the same experience. 

So it is very difficult to get that information typically. It is clearly requested by our team members at HLA, and we don’t get it. 

That being said, that information is difficult to understand. And we 

would favor information being made much clearer for the consumer. I think having boxes of information that indicate the process for determining when services are covered not only is complicated but it also I think speaks to the extreme scrutiny that 

services are given when people are trying to get coverage for them. 

So we would definitely favor clearer information be given to consumers and also clearer information on where people can get help 

if they don’t feel equipped to try to understand the materials that 

they are given, so, as Congressman Kennedy’s legislation provides, 

a central portal where people can go and indicate that they feel as 

if they have been, generally speaking, unjustly denied coverage for 

care, and maybe they don’t feel equipped to go through the documents and do the parity analysis themselves, but have an agency 

look at that complaint for them in a systematic and general and 

uniform way. 

Mr. GREEN. And I know with our mental health bill we passed— 

it is still in the Senate—we didn’t put that provision from Representative Kennedy in, but it is one we intend to do. 

Since 2010, we know there are only 140 cases in which the Federal Department of Labor has found parity violations. It seems unVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00046 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
43 

likely that the parity has been implemented so comprehensively 

nationwide that there are only 140 violations. What steps can we 

take to ensure the law is fully enforced? 

Mr. SELIG. Well, thank you for that question. I would say several 

things, and many of them are embodied in Congressman Kennedy’s 

bill, which I think is on the mark in many ways. We do feel like 

Federal reporting requirements for health plans are important, for 

health plans to be required to demonstrate how they are complying 

with parity and have that information public. 

We also think that random audits of health plans are important 

as a check on the self-reporting that insurance companies do. We 

also, again, believe strongly that there must be a simplified consumer complaint process and much greater public education that 

will help people understand what their rights are under the parity 

law and how to vindicate those rights and understand when a denial is inappropriate or maybe when it doesn’t violate parity. 

I also support some of the provisions for sure in the legislation 

that the committee did pass. The compliance program guidance 

document that was included in that legislation I think would provide a very valuable, as I said in my opening statement, kind of 

common law, a record of how the Government has interpreted certain limits by health plans and to give health plans and insurers 

a greater understanding of what are appropriate denials and what 

aren’t. 

Mr. GREEN. Thank you. We are out of time. But we even have 

problems with the physical health, because I have folks who think 

they have insurance, and they show up at the hospital that is on 

their network, and all of a sudden they find out—nowadays, the 

practice of medicine, there are different providers that are not part 

of that system. So when they leave, they find out they are out of 

network. And so it is confusing, both—the mental side probably 

worse than the physical side, but we have those problems there. 

Thank you, Mr. Chairman. 

Mr. GUTHRIE. Thank you. 

I am going to try to stick to the 5 minutes as much as possible 

so we can get more questions in. There is actually a memorial service for 9/11 coming up this morning as well. 

Dr. Bucshon from Indiana, you are recognized for 5 minutes. 

Mr. BUCSHON. Thank you very much, Mr. Chairman. 

First of all, I would just like to outline, you know, again, the 

problem, and it goes across all socioeconomic statuses. I have a 

high school friend in my class who recently died at age 54. She had 

schizophrenia. Their life expectancy is shortened. She had two children and her husband divorced her and changed the children’s 

names. And she ended up on the street because of really probably 

a multitude of factors, but one of those was her ability to get treatment. 

I also had a high school friend who came home for Christmas 

break in college and broke up with his girlfriend and a couple 

weeks later committed suicide at college. No other indication. But 

the question in my mind is, you know, on college campuses, was 

there any indication that he was struggling? 

44 

And that is true, because my son, one of his fraternity brothers 

who graduated in May and who had a job just committed suicide 

at age 22. 

So this is really something we need to address. Twenty-two veterans a week we are losing. I just wanted to outline the problem, 

as we all know, but for the record. 

And it is important to know that most mental health patients 

have other medical issues. In Indiana, there are a couple centers 

close to my district—Centerstone in Bloomington, Hamilton Center 

in Terre Haute—that coordinate both traditional medical problems 

and mental-health-related issues, including substance use disorder. 

So, Dr. Trangle, this is a subject that is really—also, I was a 

medical doctor before I was in Congress. I was a surgeon. So I understand this. 

Why do you think it has been so difficult to get mental health 

parity and treatment for mental health issues? I mean, they can 

be chronic problems, I understand. But, you know, diabetes, congestive heart failure, these are all chronic problems. Why? I mean, 

I think we all know probably the answer. But, in your experience, 

why are we still struggling to be able to have parity in how people 

are treated because they happen to have a mental health issue? 

Dr. TRANGLE. I think the tradition in medicine is to have things 

siloed up, you know, and not thinking holistically, not having people be physically in the same place, not sharing the same EMR, 

and not talking about these things. 

Some of the examples you mentioned—diabetes, cardiovascular 

disease, heart failure—have a significantly increased incidence of 

depression. If somebody has an AMI and they are depressed and 

you don’t recognize it, they will have higher mortality, not because 

of the physiology, because they don’t do their cardiac rehab. We 

need to screen for depression throughout all of primary care, 

throughout health plans’ members, and then make sure for those 

that are screening positive we follow up. Ideally, you follow up in 

primary care clinics where you don’t have to get somebody to get 

over their own stigma and go to a more embarrassing place of a 

mental health clinic. You need to be able to virtually talk to the 

primary care docs and help them with advice, with recommendations, with consults, things like that. 

Mr. BUCSHON. Mr. Selig, maybe you can help, because you are 

involved in dealing with trying to help people get coverage. I mean, 

as a healthcare provider, still for years I have had this issue. I 

mean, I had patients that were inpatients that I did open heart 

surgery on that clearly had mental health issues. I diagnosed a 

number of people who were bipolar and depressed and everything 

and had a hard time getting—there is a physician shortage, which 

we can address. 

But, in your mind, what is your opinion, what is the impetus for 

difficulty getting coverage for, say, depression versus diabetes? I 

mean, it doesn’t make a lot of sense, really. I mean, do you have 

any insight into that? 

Mr. SELIG. Well, I have a couple of thoughts about why the parity law, which is, you know, a landmark law, why it is hard to— 

has been hard to implement. First of all, there is a patchwork of 

agencies that have to enforce the law. So we have the Federal GovVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
45 

ernment, which directly enforces it with self-insured plans and also 

can provide guidance to State agencies. And then you have 50 

State agencies, divisions of insurance, and also Medicaid offices 

that all have to enforce the law in all different ways. So there is 

a patchwork of interpretations of the law. 

Mr. BUCSHON. I guess the question is, why would you need to 

have to interpret it? Why do you need a parity law in the first 

place? You see what I am trying to get at? I don’t know if we can 

answer that question today. 

Ms. GREENBERG. Dr. Bucshon. 

Mr. BUCSHON. Yes, Ms. Greenberg, do you have any insight? 

Ms. GREENBERG. If you don’t mind for a second, Mr. Selig. 

I think part of the issue too is that there is a great stigma associated with mental health and addiction. And so we have treated 

typically mental health and addiction in our healthcare system differently than behavioral health. That is not the right answer, not 

the right thing to do. But people are afraid to talk about their mental health and addiction for fear of being ostracized or—— 

Mr. GUTHRIE. We are going to have to get more questions in, so 

hopefully you will have the opportunity to answer further through 

some other questions moving forward. 

But I would like to recognize Ms. Matsui from California. 

Ms. MATSUI. Thank you very much. And I would like to thank 

all the witnesses for being here today to testify on such an important issue. 

One of the main reasons that I have heard with parity enforcement stems from the fact that there are different Federal and State 

agencies responsible for overseeing and enforcing the parity law. 

This patchwork is a little bit of the nature of the game. The Federal law sets a standard, and States can make more strict parity 

laws, which California does. And States are also responsible in 

large part for making the rules for their own Medicaid programs. 

Mr. Selig, can you give an overview of the patchwork of State 

and Federal enforcing agencies? 

Mr. SELIG. Sure. I will pick up and repeat a little bit of what I 

was just speaking about and try to do it quickly. So there is a 

patchwork of enforcement agencies that enforce the parity law. So 

you start with the Federal Government, which enforces the law for 

self-insured plans directly, because those aren’t under the regulatory purview of the States. Each State has a division of 

insuranceand an office of Medicaid that enforces the law for those 

respective plans. You also have the TRICARE agency also, as Ms. 

Greenberg indicated, has a separate enforcement mechanism too. 

So there are several different agencies that have responsibility for 

making sure the parity law is implemented and enforced. 

Ms. MATSUI. OK. Well, because much of the enforcement tends 

to be at the State level, especially for Medicaid, it follows that the 

States should learn from one another about best practices to ensure 

consistency for consumers. SAMHSA put out a report regarding 

best practices from seven States. For example, the California Insurance Commissioner’s Office worked closely with California’s exchange, Covered California, to design benefits under the parity law. 

46 

Ms. Greenberg, is the SAMHSA report helpful to your member 

companies? And what else can we be doing to share best practices, 

such as interagency coordination, across the country? 

Ms. GREENBERG. Sure. Yes. The SAMHSA document, which was 

released quite recently, is very helpful. We were actually interviewed as a part of that report. And I think sharing of the best 

practices is one of the most helpful ways to assist with parity implementation. And one of the other things that can be done, as has 

been mentioned by I think all of us, is the sharing of the identified 

information. 

So whether it be a problem that is found or something positive 

that is found by any of the agencies that Mr. Selig suggested that 

are doing the implementation, if they can let people know, this is 

a problem that we found, and this is how it should have been treated; or this is how the change was made to become parity compliant; 

or this is an instance where a plan is parity compliant, and these 

are the things that they are doing that we, the auditors, have 

found helpful. I think that information and those best practices or, 

in some cases, unfortunately, worst practices would be helpful to 

us. 

Ms. MATSUI. But how can we encourage more sharing of information at a level where actually things get done? 

Ms. GREENBERG. I think to talk—reports like the SAMHSA report, to talk with States and encourage them to release the information, and also to talk with the Federal agencies, which we and 

other stakeholders have, to encourage them to share that information. 

Ms. MATSUI. OK. Well, thank you. 

There are today up to 30 million Americans experiencing eating 

disorders during their lifetimes. However, one in 10 of these Americans will receive treatment due to a lack of early identification and 

treatment coverage. 

You know, the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act was designed to ensure health insurance plans covering mental disorders and substance use disorders would provide the same favorable level of coverage as they 

would for medical/surgical benefits. Since the law has been finalized, we have heard that there are still gaps in coverage for mental 

health disorders, especially for people with eating disorders. 

With my colleague, Congressman Lance, we led the effort to include provisions to clarify coverage of eating disorders benefits, including residential treatment, within the mental health bill that 

passed the House before the August recess. 

Dr. Trangle, in your experience, what is your understanding of 

how private health insurance contracts handle eating disorders? 

Dr. TRANGLE. Thanks for the question. I think it is a great one. 

As my organization has grown, we combined with another organization, and we now own something called Melrose Eating Disorder 

Center. And our organization is really intent upon trying to simultaneously improve the measure of the quality, patient satisfaction, 

and making it more affordable. 

As we kind of integrated this eating disorder place into our hospital, into our system, we looked at it from all different directions. 

What is the quality? Were they measuring outcomes? They weren’t. 

47 

What was the expense? It turned out our employers were complaining about the expense and the number of high-buck cases and 

were thinking about excluding eating disorders from their benefit 

sets, the self-insured employers. We looked at it and basically said: 

We want to shift this a bit. And we created levels of care, like intensive outpatient treatment teams, to be mobile and work with 

them and much more intensive. It helped us reduce the length of 

days for inpatient. We created more outpatient resources. Ultimately, people are in care longer, but it is at less expensive levels 

of care. The cost has gone down, and the outcomes have gone up. 

Mr. GUTHRIE. Thank you. 

Ms. MATSUI. Thank you. 

Mr. GUTHRIE. You might want to submit more of that to the 

record. If you want to answer more, you can submit that to the 

record. I appreciate it very much. 

Mr. Collins of New York, you are recognized for 5 minutes. 

Mr. COLLINS. Thank you, Mr. Chairman. 

Dr. Trangle, if you could speak closer. When I ask you a question, I am going to maybe 4 inches from the mike, because that is 

how sensitive they are. 

Anyhow, I want to thank the witnesses for coming, and I don’t 

think there is a family in America that is not impacted by mental 

health at one stage or another. It is such a multifaceted problem, 

I think. Unlike some traditional medical issues, I actually believe 

mental health is almost individualized to so many contributing factors. It is hard to take six patients that may seem similar and say 

that it is all the same thing. So, again, I think this is a very useful 

hearing to kind of deep dive: What is going on? How we can do better? 

Just as a point of interest, my district includes the only veteran 

suicide center in the United States. So every veteran who would 

have that unfortunate urge to commit suicide, when they call in, 

they end up at a call center in Canandaigua, New York. So I have 

spent a significant amount of time there talking to those who are 

answering the phone calls. And it just became clear that the problems ranged from opioid abuse to PTSD to then PTSD leading to 

more opioid abuse and substance abuse. It is such a tragic thing 

that is going on in this country and, in some cases, with the youth. 

So, again, I appreciate all your testimony. But I also know there 

is a balance between State regulations, Federal regulations, more 

regulations that we have to address. 

So, Dr. Trangle, I will just maybe ask my first question to you. 

Mr. COLLINS. As a clinician, would more Federal rules, more Federal disclosures, and more Federal audits, because that is what we 

are here, the Federal Government, would this help in any way 

streamline care, or as a clinician do you feel that more regulations 

at the Federal level would potentially burden a system that is already pretty highly regulated, as Mr. Selig pointed out? 

Dr. TRANGLE. Yes. Let me try and answer that. I almost feel like 

I am living in parallel universes. I think about what—— 

Mr. COLLINS. If you stand a little closer, like 4 inches—— 

Dr. TRANGLE. It feels like I have these conversations with patients and families—I am going to eat it while I talk. 

Mr. COLLINS. That is—we will use that. 

48 

Dr. TRANGLE. I feel like I live in a world where I am talking with 

patients and families kind of in the clinic, and the kind of information they want is really sort of—like last week there was a social 

worker seeing someone. And the patient was someone who was 

chronically depressed and I think beginning to get a little bit manic 

and having some kind of thought disorder. And we talked about 

what do we need to do. You know, there was not necessarily a clear 

suicidal thought, a little vague thought about a bridge. And the discussion was, does this person need to be in an inpatient unit, which 

means being locked up and much more restricted? Do they need to 

continue to see somebody once a week? No. Ultimately, we came up 

with the idea this person should go to a partial hospital program 

where they would see a psychiatrist every day, they would get 

started on an antipsychotic, talk about suicide, make sure they 

were safe. And it was not all or nothing. 

You know, you need to have some checks and balances, and people that are making the recommendations know what the resources 

are and what is the right care at the right level of care at the right 

time. 

We have similar checks and balances that we struggle with. 

Somebody came to me and said: I read about Ketamine and I know 

it works for depression and I want you to change—and our depression scores showed that she was actually getting better but not fast 

enough for her. And she said: I want you to order Ketamine and 

I want the health plan to pay for it. And this didn’t even go to the 

health plan review. I said: I am up on this literature. And 

Ketamine has a number of individual studies showing rapid response for depression, but it doesn’t last. As soon as you stop getting the IV Ketamine, you get depressed again. It is not going to 

be a good solution long term. 

You know, how do you have checks and balances to make those 

decisions and not have people like primary care docs who don’t necessarily know all the details saying: This is what I am recommending, but somebody with more knowledge is involved and gets 

the right care at the right time for the patient? It is a separate 

issue. But more is not always better. It is what you share and what 

you communicate. 

Mr. COLLINS. Yes. Thank you. 

I guess, Ms. Greenberg, let me ask you kind of a similar question. There are so many State enforcement laws, as Representative 

Matsui, you know, alluded to a Federal, State, et cetera, et cetera. 

Do you think that the State enforcement laws at that level are adequate for the oversight and parity standards or do we need more 

Federal intervention? 

Ms. GREENBERG. I think what we need is more uniformity in the 

enforcement. Whether you are a State or whether you are the Federal Government, the parity laws should be enforced consistently 

and uniformly. And if there can be some direction in that area in 

terms of education and what are the questions that an enforcer, no 

matter where they sit, should be asking to determine whether or 

not a plan is parity compliant, that would be very helpful. I don’t 

know that it has to be legislative. I think the regulators are working to get there. 

49 

Mr. COLLINS. Yes. Well, again, my time has expired. I want to 

just thank all the witnesses. This is such a complicated issue. And 

I thank Representative Kennedy for asking that we hold this hearing. And I think it is being useful. And I yield back. 

Mr. GUTHRIE. Thanks for that. I appreciate it. 

Mr. Kennedy from Massachusetts, you are recognized for 5 minutes. 

Mr. KENNEDY. Thank you. And I appreciate the kind words from 

Mr. Collins. 

A couple of quick points here. First, for Mr. Selig, I want to 

thank you again for your tireless work on behalf of the patients 

and their families. We hear anecdotes time and again about patients who struggle to get access to the care that they need. In your 

experience, what is the greatest barrier to that care, and is it insufficient reimbursement, inadequate networks, shortage of suppliers? 

And we will start there. 

Mr. SELIG. Thank you, Mr. Kennedy, very much. And thank you 

for your very hard work on this issue. 

I think that there are many barriers to mental health and substance use services. And insurance barriers are certainly a leading 

one, and that is obviously the topic of today’s hearing. That being 

said, there are other barriers to mental health and substance use 

care that I think are worth noting. 

Workforce shortages, which has been mentioned today—— 

Mr. KENNEDY. Can I push you on that one. 

Mr. SELIG. Sure. 

Mr. KENNEDY. And I just ask just because the timing is brief, we 

have restrictions here. But all of you have mentioned workforce 

shortages in your testimony. And, Dr. Trangle, you went into this 

in some detail. 

For programs that you put forth, loan forgiveness, reimbursement rates, would you support movement on all of those to address 

the workforce shortages issues? Ms. Greenberg. 

Ms. GREENBERG. Would we support—yes. 

Mr. KENNEDY. Yes. Dr. Trangle? 

Dr. TRANGLE. Absolutely. 

Mr. KENNEDY. And Mr. Selig? 

Mr. SELIG. Oh, 100 percent. Absolutely. Loan forgiveness and 

better reimbursement would be critical for that. 

Mr. KENNEDY. Great. 

Ms. Greenberg, my cousin Patrick served in the House, and he 

worked tirelessly to pass a groundbreaking mental health parity 

law. And again, I want to thank you for your early support for that 

legislation and for ABHW’s work. Years later, we worked to try to 

implement the spirit and the letter of the law. And the final rule 

for mental health parity clearly indicates that it, quote, ‘‘requires 

the criteria for planned medical necessity determinations with respect to mental health or substance use disorder benefits be made 

available to any current or potential beneficiary or contracting participant upon request in accordance with regulations,’’ end quote. 

One of the challenges we hear over and over and over again, including from my legislative director who spent, again, 2 hours on 

the phone with an insurance company whose folks, representatives, 

had no idea what she was talking about, to the extent that they 

50 

said: That information doesn’t exist. And she said: Well, then you 

are not in compliance with Federal law. I can go through the 

minute-by-minute readout. 

I understand the fact that this is very complex, and most experts 

in this room would still struggle with that level of complexity. But 

the complexity can’t be the barrier to information for a patient to 

be able to get access to that care. So how can we—how can parity 

be strengthened—the enforcement of parity—and the legislation 

that we have authored doesn’t try to touch the actual requirements 

around parity. It merely says: Shine a spotlight on it to make sure 

that the information is available so that we can ensure that parity 

is being complied with. 

So if the issue is complexity, and it has been 10 years since this 

law has been passed, can’t we find a way to simplify some of the 

information so that consumers can digest it? 

Ms. GREENBERG. Yes. I would like to work with you and others 

that are interested in this topic to try to find what is that kind of 

concise document that we can give out. And I think that would 

help insurers understand, OK, what are the components that 

should and need to be given and also help with consumers, because 

they would have then an understandable document. 

I will say that I agree with you, the medical necessity criteria 

should be disclosed. That is part of the law. Many of our member 

companies have it up on their Web site. And in that specific situation, if that is still an issue, I would like to help with that as well. 

Mr. KENNEDY. Great. And great that that was one specific company. And, you know, there is obviously many plans and challenges 

out there. But one of the challenges that we also hear over and 

over and over again is that there should be a central clearinghouse 

for—essentially, a database for issues and complaints that arise so 

that information again can come in a centralized location so that 

regulators, advocates, patients can understand what services they 

can get, what is covered, what isn’t, given the complexity of this 

law, and the challenges for it. That is part of what is contemplated 

in our legislation. 

And I would love to get your thoughts on, again, how we can ensure that the transparency requirements—we shine a greater light 

on that transparency. 

Ms. GREENBERG. Sure. And we do support the idea of a consumer 

portal that I know is in your legislation. And also we would say, 

and I think you do as well, deidentified information. 

Mr. KENNEDY. Of course. 

Ms. GREENBERG. And people always remind me to say not just 

the problems but also deidentified but show the good things that 

have happened and where there have been success stories in parity, because there are some of those as well. 

I don’t know, Congressman, whether legislation is necessary to 

do this. I think, you know, that strict and strong conversations 

with the regulators. And, frankly, we have already seen, as a result 

of the attention you have brought to this issue, guidance issued in 

the last few months on the—more guidance issued on the disclosure topics. So you are shedding a sunlight on it. 

Mr. GUTHRIE. Thanks. We are going to—I hate to—— 

Mr. KENNEDY. No, Mr. Chairman. 

51 

Mr. GUTHRIE. Mr. Kennedy, do you have other things—— 

Mr. KENNEDY. I have a number of documents I would like to introduce for the record. And, again, I appreciate the time. But a letter from a number of advocacy organizations, testimony from 

former Representative Patrick Kennedy, and a couple of letters 

from other advocacy organizations that I would like to submit for 

the record. 

Mr. GUTHRIE. Without objection, so ordered. 

Mr. KENNEDY. Thank you. 

[The information appears at the conclusion of the hearing.] 

Mr. GUTHRIE. Thank you, Mr. Kennedy. And I will compliment 

you on your passing of this as well. 

Mr. Schrader from Oregon is recognized for 5 minutes. 

Mr. SCHRADER. I yield my time to Representative Kennedy. 

Mr. GUTHRIE. Representative Kennedy is recognized. 

Mr. KENNEDY. Mr. Schrader, you are a good man. 

So let’s focus a little bit, since I have a couple more minutes, on 

the reimbursement issues. 

My understanding—again, Mr. Selig, we can start there—well, 

actually, Dr. Trangle, we can start with you. Particularly issues 

around Medicaid. If you could talk a little bit about how low reimbursement rates affect, in your opinion, the access to care that professionals are able to provide for the poor. 

Dr. TRANGLE. You know, I know I read an article that came out 

just this past week, I think it was in JAMA, where they talked 

about—it did document some variability there, as well as sort of 

variability in how many psychiatrists were participating in what 

plans. So I know there is data out there nationally of how that 

plays out. 

In our area, I don’t think we necessarily—what we have are psychiatrists that opt out of the system totally and will take cash only 

and take nobody with insurance, is the bigger issue in our area 

versus not taking one versus the other. 

Mr. KENNEDY. Generally—— 

Dr. TRANGLE. Workforce issues for general population, especially 

the mentally ill. 

Mr. KENNEDY. So generally speaking, looking at insurance rates, 

reimbursement rates, private insurance generally reimburses at a 

higher rate than Medicaid would. Fair? 

Dr. TRANGLE. Correct. 

Mr. KENNEDY. So one of the challenges that we have faced, even 

over the course of the past couple years, is that we have been 

searching for information about Medicaid’s reimbursement rates for 

mental health services. Not the joint Federal/State program, CMS 

actually doesn’t compile a national database of what those rates 

are. 

So I was wondering, Ms. Greenberg, is there some information 

that, given the companies that you represent and the scope that— 

the number of States that your companies practice in, that data 

clearly exists, it is just that the Federal Government doesn’t have 

access to it because, in our conversations even with CMS, they 

have indicated the nature of a joint Federal/State program, that information is lodged in the States and many of those States aren’t— 

52 

they are not required at all to divulge that reimbursement rate information to CMS or to the Federal Government. 

You guys obviously deal with those issues on a daily basis. Is 

there a way that we can try to ascertain, that this committee can 

ascertain, what reimbursement rates look like for Medicaid across 

the country? Can you help with that? 

Ms. GREENBERG. I would be happy to try. To be honest, it is not 

an issue that I have—or the question that I have asked before of 

our member companies. But I certainly would be happy to ask 

them that question and see—or maybe they don’t—they don’t have 

it or can’t give it out, but maybe they know someone in the State 

level that can help with that. So yes, I would be happy to look into 

that. 

Mr. KENNEDY. It just strikes me as we have heard some of the 

challenges of parity, but we have also heard from all of you today 

the struggles with workforce. If we are looking at struggles with 

workforce and Medicaid is the largest payer of mental health services in this country, that if we are not looking at reimbursement 

rates as one of the drivers for workforce shortage, then it is tough 

to address that issue for workforce if we are not looking at the compensation mechanisms for those professionals. 

Ms. GREENBERG. Sure. Yes. 

Mr. KENNEDY. Do you want me to keep going? 

Mr. SCHRADER. Sure. 

Mr. KENNEDY. Great. 

So if I can continue, Ms. Greenberg, so insurance companies 

often state that they are making efforts to comply with the law. 

And in your testimony with mental health parity, your testimony, 

you indicated that. Why is it that given a good-faith effort to comply with the law, why is it that 10 years on we are still struggling 

with the actual receipt of that information and struggling with patients being able to gain access to the care that they need when 

they need it and even understand what services are available to 

them? 

Ms. GREENBERG. There are so many reasons. You know, it is, as 

I think everybody knows, it is a complex law and regulation. The 

regulations came much later than the actual law did. So enforcement of the law began—or, sorry—of the final regulations began in 

2014. So while the law passed in 2008, the regulations haven’t been 

in effect for as long a period of time. 

I think also we have seen some things, like some of the larger 

disclosure issues have come later through guidance that has been 

issued by the regulators versus the initial disclosure that specifically was around medical necessity criteria and reasons for denial. 

And through guidance we have seen that expand a little bit. So trying to get our head around, OK, what are those documents that 

you are talking about, what format, you know, as we have discussed here today, are you looking for that information? And it is— 

as I mentioned in the testimony, we have had dozens of meetings 

with regulators. There are gray areas, as there are with all regulations, that we have spent countless hours trying to understand. 

Mr. PITTS [presiding]. Thanks. 

Mr. Kennedy’s time has expired. Dr. Schrader, we have a 9/11 

memorial service at 10:30 I know some of us are trying to get to. 

53 

But Ms. Castor from Florida, you are recognized. 

So I apologize for cutting you off. 

Ms. CASTOR. Thank you, Mr. Chairman. I want to thank Congressman Kennedy and Congressman Green and all of my colleagues for continuing to focus on mental health parity for our 

neighbors back home. And thank you to the witnesses. 

There have been many significant changes to mental health parity and substance abuse parity over the past decade. And as a legislator, it is important to know what is happening in the real 

world, how does this play out for families. 

Mr. Selig, your organization, Health Law Advocates, represents 

Massachusetts residents in mental health and substance abuse disorder parity cases. You also communicate with other advocacy 

groups across the country that are engaged in similar work. Based 

upon your experience, what is the most common type of potential 

parity violation you encounter? Or are there a few different ones? 

Mr. SELIG. Thank you for the question. There is no question, as 

I said, that among the people we represent, mental health and substance use care is harder to access than other types of care. That 

is our experience, and that is the experience that is communicated 

to us by other advocates and providers out across the country. 

The insurance limits that we see most frequently are things like 

arbitrary limits on things like residential stays for substance use 

disorders. You know, we have seen several patients, for example, 

who have lost their coverage for residential substance use treatment, regardless of their condition, after 2 weeks. It is like a hard 

stop and then that is it and then services are stopped. So that is 

something that we see as a significant barrier. 

The full range of scope of services is also something that we see 

not being provided to consumers. So especially intermediate services, intensive outpatient services. Again, residential care and other 

types of services that aren’t acute and aren’t outpatient are very 

common. 

As I mentioned, we also see unusual limits on medication assisted treatment that seem to be arbitrary and don’t necessarily 

align with what our review of the medical necessity requirements 

are. So those are some. Also—— 

Ms. CASTOR. But when you raise the issue with insurance providers, typically is it remedied or is it a fight? 

Mr. SELIG. So, you know, it really runs the gamut. When we talk 

to health plans on behalf of our consumers, sometimes we are able 

to remedy the problem. We will be able to provide a certain amount 

of information or provide some clarity on the situation or an analysis of the parity law, in some cases, where we may say we think 

that this process counters the parity law and the health plan will 

change its course. In other situations, we will go to appeals internally with the health plan, externally, and we will raise the issues 

that way. And in a good portion of the cases, those appeals do result in an overturning of the decisions that are made by the health 

plan. 

So we have a pretty good record, I think, a very good record, actually, when insurance denials occur in changing the outcome. 

54 

Ms. CASTOR. It is really too bad that folks need an advocate at 

all, because they are dealing with the personal issues every day. 

And thank you for what you are doing. 

Congressman Kennedy raised the point of Medicaid reimbursement rates. And I know my colleague, Mr. Green from Texas, 

would agree that the fact that Texas and Florida have not expanded Medicaid at all is a real barrier to so many of our families 

receiving the care they need. Do you have an opinion on what Medicaid expansion has meant for families and mental health treatment across the country? 

Mr. SELIG. Well, I think the Medicaid expansion really has provided just incredible financial stability and support for State Medicaid programs which enable them to support the, you know, really 

the entire range of services that members are entitled to, but specifically mental health and substance use services, which are typically, you know, and historically shortchanged. So I think it has 

been just hugely successful in that way. 

More people are enrolled in insurance, obviously, because of the 

expansion. People have better coverage. And so I would—you know, 

undeniably, the expansion has, in all sorts of different ways, helped 

people throughout the country access mental health and substance 

use services. 

Ms. CASTOR. I hope they hear that back home in my State capital. The most important thing for the mental health of a lot of my 

neighbors would be for the State of Florida to expand Medicaid. So 

thank you very much. 

And I yield back. 

Mr. GUTHRIE [presiding]. Thank you, Ms. Castor. 

I recognize Mr. Luja ́n from New Mexico for 5 minutes. 

Mr. LUJA ́ N. Thank you very much, Mr. Chairman. 

Well, I am a cosponsor of Congressman Kennedy’s legislation and 

I applaud all the work that Congressman Kennedy is doing in this 

space to continue much of the work that has been done by the Kennedy family and carrying on with the work that was done by both 

Senator Paul Wellstone and Senator Pete Domenici, senior Senator 

from my home State of New Mexico. 

In New Mexico, right now, we have an issue before us where the 

State of New Mexico under Governor Susana Martinez unnecessarily suspended payments to 15 behavioral health providers, 

claiming fraud. And the system was thrown into chaos. Now, even 

though every provider has been exonerated by the attorney general 

of the State of New Mexico, many of these providers have been 

forced to close their doors. And we all know who is left out. It was 

patients. It was the people that needed help the most. 

And so, Mr. Selig, can you talk to us about what such a disruption means for someone struggling with mental health issues? If 

their provider is suddenly gone, the trust that is established to try 

to get back in that door, what does that mean to someone that is 

struggling with mental health issues to try to get the support they 

need? 

Mr. SELIG. Well, that sounds like a very regrettable situation, 

and I am sorry to hear about that situation in New Mexico. We 

represent, again, a lot of people who have mental health services. 

And when they are denied coverage, their services are interrupted. 

55 

And we have seen really catastrophic effects for people. Their conditions get much worse. Someone with a eating disorder, for example, which is a high priority for us, who needs a particular level 

of treatment and is denied that level of treatment and is only provided access to a much lower level of care, really, their life is going 

to be in danger. And that person is really gravely at risk. Also, 

there is absolutely a connection between lack of addressing mental 

health and substance use services and deterioration of other health 

conditions. So when people aren’t getting mental health services, 

other health conditions will suffer too. So people aren’t as able to 

attend to situations like perhaps heart disease or diabetes. 

So really, there is a cascading effect when people aren’t able to 

access mental health and substance use care that I think is really 

life threatening and disruptive, you know, to their lives and livelihoods for sure. 

Mr. LUJA ́ N. Well, along the same questions that Congresswoman 

Castor was asking that Congressman Green had put on the table 

with concerns of States that did not have Medicaid expansion. In 

New Mexico right now, what we are seeing is the State recently 

made a decision to cut provider Medicaid reimbursement by $400 

million. And especially with the shakeup with the mental behavioral health system, we have grave concern and we are looking for 

some support. 

But specific to the reimbursement rates, Mr. Selig, is a low reimbursement for behavioral health providers in the Medicaid program 

an impediment to ensuring robust access? And how can we encourage more participation of behavioral health providers in the Medicaid program? 

Mr. SELIG. I mean, I think thereis no question. I mean, that is 

what we hear from providers. They would love to be able to provide 

the services, be reimbursed through insurance. I think the rates 

are an important factor alongside the other burdensome kind of criteria that health plans place upon them. 

But going back to the rates, I think that it is absolutely connected to the inability of consumers to access providers because 

they are not in the network, because providers choose not to accept 

insurance because of low reimbursement rates. In Massachusetts, 

we have recently been able to increase, actually, reimbursement 

rates for outpatient providers. So we really applaud our State government for doing that. I think there is more work to do in that 

area, but that has been very well received by the provider community in Massachusetts. And I think it is going to have some impact 

going forward. So we would encourage other States to do the same. 

Mr. LUJA ́ N. I appreciate that. And, Mr. Selig, the other question 

I had for you you actually addressed, which was the impact to 

someone’s physical health if they are not able to get the mental 

health care that they need. And you described exactly that impact. 

So I appreciate you addressing that. 

And, Mr. Chairman, you know, while I hope that the committee 

and the Congress will move forward to support Congressman Kennedy’s legislation, I think the aspects that Congressman Kennedy 

also raised, which was brought up by our panelists today, about the 

importance of making sure that we have enough providers available to see everyone that needs care is something else that we need 

56 

to take seriously. And the mental and behavioral health bill that 

passed the United States House of Representatives currently still 

needs to be funded. And I think everyone on this panel would support full funding of that legislation. And so I look forward to working with our colleagues to get that done. 

Mr. GUTHRIE. Thank you. 

And Mrs. Capps from California, you are recognized for 5 minutes for questions. 

Mrs. CAPPS. Thank you, Mr. Chairman. And thank you all for 

your testimony. And I want to echo the thanks to our colleague Joe 

Kennedy for making sure this topic is received in this hearing. I 

hope it won’t be the last one. I hope it is the first of really getting 

into this issue and doing some of the work we haven’t done yet. Because for too long we have artificially looked at behavioral health 

as totally separate and unrelated to physical health. My previous 

questioner just made that point. But I want to go into it. 

Because we know that the two are so intrinsically linked, we 

need to ensure that our public policy recognizes the important fact 

that if we ever really want to help our Nation become more healthy 

and productive, this topic needs to be addressed. I am proud of the 

work that Congress has done over the years to address parity between the behavioral health and physical health services. And I 

want to be clear. We have come a long way, but that is not enough. 

What we have done is not enough. 

Too many individuals are still falling through the cracks. Too 

many communities, as we have heard, are unable to support those 

in need of affordable behavioral health services, even though the 

treatments are there and the results have been documented. I believe we have missed an opportunity to take the next necessary 

steps to address this issue in mental health legislation we considered here in this committee earlier this year. 

So today’s hearing is a chance to reinvigorate this conversation, 

help guide this committee to do what is necessary to ensure that 

individuals get the care they need when they need it. 

Mr. Selig, I know you have been questioned, but you see the 

shortcomings in this current system so well. And while we know 

that these issues affect all in need in one way or another, I wonder 

if you would speak a minute about the compounding effects on 

more vulnerable and underserved populations like children. 

It is estimated that at least 13 percent of children are affected 

by mental disorders in a given year. Unfortunately, we know that 

pediatric specialists are few and far between. So in your experience, how does this lack of coverage affect children? Are there any 

unique access issues faced by children? You mentioned eating disorders, and that is just one. Is there a difference for children in 

Medicaid and CHDP and those with private insurance? 

Mr. SELIG. Well, thank you for raising that, and particularly, 

Mrs. Capps, for highlighting the needs of children. There is, you 

know, no higher priority for our organization than trying to access 

mental health and substance use services for children. We do see 

specific types of services that are harder—that children have difficulty accessing. I mentioned a couple of them. 

Children with autism, very difficult to access, especially applied 

behavioral analysis services. Eating disorders you mentioned, anVerDate Mar 15 2010 12:24 Oct 12, 2017 Jkt 037690 PO 00000 Frm 00060 Fmt 6633 Sfmt 6633 I:\114THCONGRESS\114X167MENTALHEALTHJKTREQ083117\114X167MENTALHEALTH
57 

other. And there are also, I would mention, many children, simply 

there is a long wait for services. Authorization for coverage may be 

in place, but—and this particularly speaks to children on Medicaid 

in our State. There can be lengthy waits for services, and I think 

that also connects to the issue of the availability of providers. 

So I would say that, you know, children, as much as any other 

population, are impacted by this kind of thing. They have very special needs. They see different providers than other people, obviously, and their needs are complex and they are intermingled with 

school concerns and family concerns. And so we are very cognizant 

of the needs of children and pay very close attention to them. 

Mrs. CAPPS. Thank you. You know, I so agree. I noticed so 

many—the many years that I worked as a school nurse, having a 

child on a waiting list is—in Congress in so many ways, because 

they change so dramatically over the months. Sometimes it is 

years. And by the time they can be treated and seen, those symptoms they had have exacerbated and become so much worse. And 

so the impact is so much more than their health. It affects their 

education, their ability to learn and work. It sets them on a pathway that is destructive, not opportunity challenging. 

And it is clear to me that any barriers to getting the care they 

need are not only harmful for the child, they really impact our society as a whole. The whole family is affected by it. It is really an 

urgency. And that is why we have to make sure that these services 

become more available. 

Again, I want to salute my colleague Joe Kennedy, and pledge 

my support for making sure this topic stays on the table and that 

it actually goes somewhere further. Thank you very much. 

And I am yielding back. 

Mr. GUTHRIE. Thank you. 

I also want to thank Mr. Kennedy and Chairman Upton and Vice 

Chairman Pitts for working together to make this hearing come together. I thank the witnesses for being here. I think that concludes 

all of our questions. 

Mr. KENNEDY. I will take them if I got time. 

Mr. GUTHRIE. Well, no, the 9/11 memorial is coming, and as of 

now—I want to remind members they have 10 business days to 

submit questions for the record. And I ask the witnesses to respond 

to the questions promptly. Members should submit their questions 

by the close of business on Friday, September 23. 

So you have an opportunity to submit more questions, Mr. Kennedy. 

And the subcommittee stands adjourned. Thank you for being 

here. 

[Whereupon, at 10:31 a.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

PREPARED STATEMENT OF HON. BEN RAY LUJA ́ N

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was a signature achievement of New Mexico’s longest sitting Senator, Pete 

Domenici. It was through his perseverance and that of Senator Ted Kennedy and 

Representatives Ramstad and Patrick Kennedy that Congress finally passed The 

Parity Act. 

But it was just a first step. I thank my colleague and friend, Congressman Joe 

Kennedy, for his efforts to build on his family’s legacy and I look forward to working 

58 

together to secure passage of more robust legislation that expands coverage for some 

of our most vulnerable citizens. 

As we all know, parity laws are undoubtedly a crucial step, but laws mean very 

little without access to mental health service providers and mental health facilities. 

In my State, we do not have a functioning mental and behavioral health system. 

When the State of New Mexico decided to unnecessarily suspend payments to 15 

behavioral health providers claiming fraud, the system was thrown into chaos. Now, 

even though every provider has been exonerated of the charges leveled against 

them, the damage has been done—providers have been forced to close their doors 

and continuity of care has been disrupted for vulnerable New Mexicans. 

I hope today’s hearing will bring light to the many challenges faced by our mental 

health system and will serve to educate all of my colleagues on the importance of 

strengthening mental health parity laws and expanding access. Everyone deserves 

to live their healthiest lives, and mental health is no exception. 

This should not be a partisan issue—it is simply the right thing to do. 

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