Docket: CMS-2009-0040 

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

Comment On: CMS-2009-0040-0048 

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

Addiction Equity Act of 2008 

Document: CMS-2009-0040-DRAFT-0105 

PA 

Submitter Information 

Name: Sabrina Tillman-Boyd 

Address: 

Harrisburg, PA, 17105 

Organization: PA Department of Public Welfare- Office of Mental Health and Substance Abuse 

Services 

General Comment 

See attached file(s) 

Attachments 

PUBLIC SUBMISSION 

As of: May 04, 2010 

Received: May 03, 2010 

Status: Draft 

Category: State Government - G0010

Tracking No. 80ae5df2 

Comments Due: May 03, 2010 

Submission Type: Web

CMS-2009-0040-DRAFT-0105.1: PA

Page 1 of 1

file://C:\Documents and Settings\baum.beth.EBSADOL\Local Settings\Temp\Temporary Di... 5/5/2010
May 3, 2010 

TO:

Internal Revenue Service 

Department of the Treasury 

Employee Benefits Security Administration 

Department of Labor 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

FROM: 

The Office of Mental Health and Substance Abuse Services (OMHSAS) 

Pennsylvania Department of Public Welfare 

Re: Interim Final Rules under the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act of 2008 (published in 75 Fed. Reg. 5410 et seq.) 

VIA EMAIL: E-OHPSACA.EBSA@dol.gov

To The Departments: 

The Office of Mental Health and Substance Abuse Services (OMHSAS) appreciates the 

opportunity to comment on the interim final rules (IFR) for the Paul Wellstone and Pete 

Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) published 

on February 2, 2010 in the Federal Register. We are optimistic that, with the passage of 

this seminal legislation, health insurance discrimination against individuals needing 

treatment and seeking equity in coverage for mental health and substance use disorders 

will be mitigated. 

1. We agree with and support the parity standard devised by the Departments 

as one that ensures that persons who utilize mental health and substance 

use benefits are not discriminated against in health plan benefit design. 

We also agree with the Departments’ determination that the MHPAEA 

prohibits health plans from applying separate deductibles, out-of-pocket 

maximums or other cumulative financial requirements on mental 

health/substance use disorder benefits. 

We agree that the parity standard devised by the Departments fully and 

appropriately implements the statutory requirement by MHPAEA. Specifically, the 

IFR reflects the MHPAEA requirement that a group health plan that provides both 

medical/surgical and mental health/substance use disorder benefits must ensure 

that the financial requirements and treatment limitations applicable to mental 
health/substance use disorder benefits are no more restrictive than those 

requirements or limitations placed on medical/surgical benefits. While the 

statutory language of MHPAEA is ambiguous concerning separate deductibles, 

out-of-pocket maximums and other financial requirements, the IFR makes clear 

that the goal of the legislation was to end benefits discrimination against mental 

health and substance use disorder services in enacting the law. Hence, plans 

that apply separate deductibles, out-of-pocket maximums or other requirements 

on plan enrollees for mental health/substance use disorder services, when such 

requirements are not imposed on other services, are engaging in a form of 

discrimination banned by the new parity law. Insofar as individuals and families 

seeking behavioral health treatment often faced additional costs associated with 

seeking services, this disparity often created a barrier forcing many to forego 

care. By prohibiting separate cumulative financial requirements, OMHSAS is 

optimistic that the MHPAEA will result in increased access to treatment for many 

individuals and their families. 

2. Additional clarification is needed concerning the applicability of both 

MHPAEA and the IFR on Medicaid funded managed care plans 

As a State which has implemented Medicaid funded behavioral health managed 

care statewide, we are keenly interested in the applicability of both the MHPAEA 

and the IFR to our current system. We understand that insofar as the IFR does 

not contain an exemption for Medicaid managed care plans and that the 

Medicaid statute requires that Medicaid managed care plans comply with the 

parity provisions of the Act, we understand that the MHPAEA applies to states 

that contract with one or more MCOs or PIHPs to provide medical as well as 

mental health and substance abuse benefits. We further understand that the Act 

does not apply to a state’s Medicaid State Plan if a state does not use MCOs or 

PIHPs to provide these benefits. However, if a state uses one or more MCOs or 

PIHPs in some but not all areas of the state, does the MHPAEA apply only to 

those areas where both medical and behavioral health are administered through 

an MCO and/or PHIP? Additional clarification would be helpful in this regard. 

3. Greater Clarification needed concerning scope of Service Parity and 

Clarification of Benefits 

The regulations create six classifications of benefits for the purpose of applying 

the parity rules; 1) inpatient, in network, 2) Inpatient- out of network, 3) Outpatient 

in-network 4) Outpatient out-of network 5) Emergency Care, 6) prescriptions. 

The rule does not define levels of care, provider types or service levels beyond 

the broad definition of “Classification of benefits.” Provider types in Pennsylvania 

vary greatly in public sector behavioral health-there are many more providers that 

may not hold professional credentials and there are no comparable medical 
services associated with a medical plan’s 100% RBRVS. For example, peer 

support, case management or intensive in-home services may be delivered by 

consumers or paraprofessionals. Additional clarification may be needed 

concerning whether these provider types fall within the scope of services subject 

to parity. Additionally, greater clarity may be needed concerning how services 

which seem to fall outside of the defined categories will be classified. 

4. More clarification needed regarding Treatment Limitation: Quantitative v. 

Non-Quantitative Service Limitation 

The rule defines treatment limitations to include both quantitative treatment 

limitations (a limitation that is expressed numerically, such as an annual limit of 

30 outpatient visits) and non-quantitative limitations (a limitation that is not 

expressed numerically, but otherwise limits the scope, time or duration for 

treatment benefits). The IFR provides that a permanent exclusion of all benefits 

for a specific condition or disorder is not a treatment limitation. It could be 

argued that a plan could totally exclude coverage for a mental health and/or 

substance use disorder and not violate MHPAEA. Once a plan covers such 

benefits, however, such coverage must be in parity with the coverage for 

medical/surgical benefits under the same plan. 

More guidance is needed on the non-quantitative treatment limitations that have 

to be “comparable to and applied no more stringently than the processes/factors 

used to apply MH and SUD benefits in the same classification”. Assuming the 

IFR is applicable to managed care environments, this would impact how medical 

management determinations are made at the plan level. 

While the IFR seems clear in the preamble that managed care practices continue 

to help reduce the cost of care, it also states that no findings will be made 

regarding the differences between the type and nature of treatment needed for 

medical surgical care and the nature of treatment needed for mental health and 

substance abuse. Insofar as the IFR does not appear to recognize distinctions 

between types of care, is it anticipated that two very different types of care be 

treated identically? It is unclear how plans will accomplish and manage 

compliance in this regard. 

Thank you for your consideration of our comments.