Docket: EBSA-2009-0010 

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

Comment On: EBSA-2009-0010-0409 

Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0691 

Comment on FR Doc # 2010-2167 

Submitter Information 

Name: Sheryl Bonner 

Address: 

P.O. Box 9201 

Austin, TX, 78759 

Email: sheryl@boonchapman.com 

Phone: 512-454-2681 

Organization: Boon-Chapman Benefit Administrators 

General Comment 

See attached file(s) 

Attachments 

PUBLIC SUBMISSION

As of: May 03, 2010 

Received: May 03, 2010 

Status: DoNotPost 

Tracking No. 80ae59c6 

Comments Due: May 03, 2010

Submission Type: Web

EBSA-2009-0010-DRAFT-0691.1: Comment on FR Doc # 2010-2167

Page 1 of 1

https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 5/3/2010
Boon‐Chapman is a third party administrator headquartered in Austin, Texas.  We administer self‐

funded plans sponsored by employers. We appreciate the opportunity to submit this comment.

We are concerned that the limited benefit classifications provided in Interim Final Regulations will

create adverse and unintended consequences.  The problem results from the outpatient/ in‐network

and outpatient/ out of network classifications being too broad.  These categories include, among other

things, outpatient hospital services, physician office visit services (primary care and specialty) and

wellness services.

Most plans provide for different benefit structures for some, if not all, of these categories.  For

example, many plans cover outpatient physician services at 100% after the participant pays an office

visit copay of $20‐$40. Further, a lot of plans impose a higher copay for specialty services to incent

primary case usage. Also wellness is often covered at 100% with an annual limit of $500‐$1000. Whereas

other outpatient services (including hospital services) are subject to a deductible and are then paid at

80‐90% of charges up to an out‐of‐pocket maximum of $2000‐$5,000.

I have outlined a sample plan design below to help illustrate the problem. This is a common plan design

for out‐patient services. Assume for simplicity’s sake assume the plan only covers in‐network outpatient

services for employees.

Coverage Categories

1) Physician office visits‐$20 copay then plan pays 100%.  

2) Wellness services‐100% coverage up to a $500 annual maximum.

3) All other outpatient services‐ $500 deductible then 90% coverage up to a $2,000 out‐of‐pocket

maximum.  

The regulations prevent a plan from imposing a financial requirement that is more restrictive than the

predominate financial requirement that applies to substantially all medical/surgical benefits in a

classification. Each of the three coverage categories above imposes a separate financial requirement. It

is unlikely that any one of them will meet the two‐thirds/substantially all requirement. Therefore, all in‐

network outpatient services for mental health must be paid 100%, without a copay or a deductible.

This isn’t the intention of the law and would strongly encourage plan sponsor to eliminate mental health

coverage and should be corrected by adding additional categories for out‐patient hospital services,

wellness services, specialty physician office visits and primary care physician office visits.   

We are also concerned with prescription drug benefits. Under the interim regulations if a plan provides

mental health coverage in any benefit classification, it must provide the coverage in all categories in

which the plan covers medical/surgical benefits. This seems only fair, but with prescription drugs it is

problematic.
Most plans that don’t cover mental health benefits generally don’t exclude prescription drugs

prescribed for mental health conditions. Our experience is that they don’t impose this limitation on

prescription drugs because the cost and participant inconvenience is too great.  This is because

prescription drug claims (unlike medical claims) are submitted without a diagnosis and many drugs can

be used for the treatment of mental health and medical/surgical conditions. To enforce the mental

health prescription drug exclusion, the pharmacy would have deny any claim that could have been

prescribed for a mental health condition. This will often occur while the participant is waiting at the

pharmacy. If the prescription was for a medical/surgical diagnosis the participant would have ask her

physician to submit a letter of medical necessity confirming that fact. Then the letter would have to be

reviewed by the Pharmacy Benefit Management Company (PBM). Next an override would need to be

placed in the PBM’s computer system, allowing the participant to return to the pharmacy and obtain her

prescription. This would create unnecessary expense and member dissatisfaction. We recommend that

mental/nervous prescriptions be allowed to be covered, regardless of whether a plan covers

mental/nervous benefits in the other classifications.