Nurses United for Responsible Services 

P.O. Box 620024, Newton, MA 02462-0024 

Telephone: 617 332-0422 Facsimile: 617 332-0423 

Email: sreyn-jwil@comcast.net 

May 2, 2010 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Room 445-G, Hubert H. Humphrey Building 

200 Independence Ave., SW 

Washington, D.C. 20201 

Re: File Code: CMS-4140-IFC 

Dear Sirs: 

On behalf of Nurses United for Responsible Services (NURS), I am offering comments relative 

to File Code CMS-4140-IFC; Interim Final Rules Under the Paul Wellstone and Pete Domenici 

Mental Health and Addiction Equity Act of 2008 (MHPAEA). NURS is the only organization in 

the Commonwealth of Massachusetts that represents only advanced practice psychiatric nurses 

(psychiatric clinical nurse specialists and psychiatric nurse practitioners). There are over 1200 

advanced practice psychiatric nurses in the Commonwealth. We provide both psychotherapy and 

psychopharmacology services, have regulatory authority for guardianship and commitment 

evaluation procedures and have hospital medical staff privileges. 

We think these regulations are extremely important and hope they are officially promulgated. 

The importance of parity has been legally sanctioned in Massachusetts, the first parity law 

having been passed in 2000; and in 2008 another parity law expanded the scope of the first one. 

The passage of these laws has helped equalize the insurance treatment for behavioral health, 

primarily by removing arbitrary day and dollar benefit limitations for certain conditions. 

However, these laws have done little to nothing towards reducing the inordinate micromanagement and oversight by insurance carriers. There is heavy utilization of insurance and/or 

carve-out agency reviewing in Massachusetts. This oversight, both in the private and public 

sectors, is often far more rigorous for behavioral health than it is for medical/surgical services in 

the areas of pre-admission screenings; concurrent reviews; the application of medical necessity 

standards; and drug coverage. Clinicians and hospitals repeatedly struggle to get managed care 

reviewers to approve services that the treating clinicians believe are medically necessary. 

Providers are constantly questioned and micro-managed by insurance reviewers as to the medical 

necessity of a given behavioral health service. Evidence of the difficulties our patients and 

clinicians experience in this regard is demonstrated by the fact that behavioral health is the most 

consistently appealed health service to our Massachusetts Office of Patient Protection, usually at 

least double the next highest appealed condition (see www.mass.gov/dph/opp). In Massachusetts, 

we believe the scrutiny for physical health is nowhere near the level of scrutiny for behavioral 

health. Because of this situation, NURS has actively supported both current versions (S.482 and 

H.1079) and past versions of the state bill, An Act to Further Define Adverse Determinations by 

Insurers which would defer the determination of medical necessity of treatment to the judgment 

of the treating clinician, rather than the insurance carrier and/or it’s carve-out agency, unless 

there is a preponderance of evidence to the contrary. 
Given the above situation we believe the proposed federal regulations, particularly in the area 

of “non quantitative” treatment limits, are vitally important and must be maintained in the 

final regulations. Our understanding of the non quantitative proposed rule is that treatment 

limitations can be no more stringent for mental health or substance abuse than they can be for 

medical/surgical benefits. Our Massachusetts experiences would lead us to believe this provision 

is critical towards implementing true parity because we have seen through nearly ten years of 

parity laws that removal of day and dollar limits essentially does not lead to parity if the 

behavioral health services are going to be more rigorously managed, scrutinized and denied by 

insurance carriers and/or their carve-out agencies. Parity with medical/surgical benefit 

management would be a major step forward in providing better access to needed services for 

the patients we serve and in essence would help lead towards true parity, which is what we 

believe Congress intended. We hope that the federal agencies adhere to this language in the final 

regulations; for without such a provision it is difficult, if not impossible to achieve true parity for 

mental health and substance abuse services. 

We are also requesting that there be clarification in the final regulations that the plans provide all 

levels of essential behavioral health services -- from outpatient, transitional/partial to intensive 

inpatient levels of care -- just as they do for medical/surgical services. In order to have parity, 

the scope of services should be comparable for behavioral health and medical/surgical services. 

We appreciate the opportunity to provide these comments and would be happy to offer more 

information, if needed. 

Sincerely, 

Sharon Reynolds 

Sharon Reynolds 

Legislative Committee Chair