File Code CMS-4l40-IFC

The National Association of Social Workers (NASW) applauds the U.S. Departments of

Labor, Health and Human Services and Treasury for their attention to the experiences of patients

seeking treatment for mental health and substance use disorders (MH SUD) and the barriers to

treatment occasioned by health plan structures and practices. The Interim Parity Rule (IPR) is

consistent with the requirements ofthe Paul Wellstone and Pete Domenici Mental Health Parityand Addictions Equity Act of 2008 (MHPAEA) without unduly expanding or limiting its

application. The IPR supports the purpose ofthe MHPAEA for the benefit of consumers ofMH SUD services and recognizes the complex and significant relationship between health plancoverage for treatment and access to treatment.

The examples provided by the regulatory agencies offer a usefUl understanding of how

the rules are to be analyzed and applied, although there are some areas where fUrther clarificationwould be beneficial, as the Departments have suggested in the request for comments. The

Interim Parity Rule implements the MHPAEA’s groundbreaking measures to improve patient

access to MH SUD coverage in a robust manner. The regulatory agencies have demonstratedresponsiveness to the concerns of health care consumers and MH/SUD providers in crafting anInterim Rule that supports the letter and spirit ofthe MI-IPAEA and that reflects an

understanding ofthe comments submitted by interested organizations at the initiation oftherulemaking process.

Clinical social workers are the largest single group of mental health providers in the

United States and their work encompasses patients and clients in a wide range oftreatment andcommunity settings, addressing those of all ages with both mental health and substance use

disorders. Clinical social workers’ ability to serve patients and clients has been hampered in thepast by the inequitable treatment of MH SUD within health plan protocols. The MI-IPAEAeffectively addressed this for larger employers’ health plans and the IFR implements the statute

750 First Street NE, Suite 700, Washington, DC 20002-4241

(202) 336-8200 FM 202) 336-83 3 bcIork@naswdc.org v.ww.sociolworke,s,org
1. We appreciate that the parity standard devised by the Departments is one that ensures that

mental health and substance use benefits are not discriminated against in how health planbenefits are designed. We strongly agree and support retention ofthe standard for annual

and lifetime dollar limits to be treated similarly for MH/SUD benefits and

medicaL/surgical benefits.

2. We appreciate that the Departments address the status of non-quantitative treatment

limitations in the IFR. The manner in which provider reimbursement rates, admission to

provider networks and methods for determining usual and customary and reasonable

(UCR) rates may or may not be applied by health plans to meet parity requirements is of

particular interest to clinical social workers and the addition of specific clinical socialworker examples to the fmal rules would be appreciated.Licensed clinical social workers are excluded from reimbursement in some health plansalthough they are licensed by the state to provide mental health services and recognized

within the HIPAA regulations and the Medicare program and other federal programs as

eligible providers that are covered by federal law. We would appreciate clarification that

when health plans provide coverage for MH/SUD benefits they must include clinicalsocial workers and other primary groups of licensed providers that are qualified toprovide these services.

The application of UCR rates to mental health providers has been carried out in a mannerthat is not transparent so that patients of out-of-network providers are unable to ascertain

at the initiation oftreatment what will be their level of financial responsibility. The

method for determining UCR rates and applying them to patients’ coverage needs to be

applied equitably for MH/SUD treatment and medical/surgical treatment.

3. NASW agrees that the parity standards should apply to medical necessity exclusions from

coverage. The manner in which the IFR addresses medical necessity exclusions is of

particular interest to clinical social workers. In the context of MH/SUD treatment, the

content ofthe patient’s clinical sessions is crucial to providing service; however, health

plan access to highly sensitive personal information also creates significant privacyconcerns that impact the patient’s trust in the therapeutic process and ultimately the

patient’s progress toward wellness. We would like for the Departments to provide
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provided covered services for a health plan member should have access to the medical

necessity criteria and the regulations should be revised to require disclosure to “providerswho render covered services to plan members.”

5. NASW suggests additional clarification on the acceptable and unacceptable parameters

for the exclusion of specific conditions or disorders, so that the purpose ofthe law is not

thwarted. May a health plan arbitrarily determine which disorders or conditions to

cover, or must a diagnosis-specific exclusion be based on some reasonable, science-basedcriteria? NASW requests additional discussion of acceptable and unacceptable disorderspecific exclusions from coverage or acceptable and unacceptable examples ofthe bases

on which such exclusions may be made.

We appreciate the opportunity to comment on the Interim Final Rule and look forward to the

enhancement in patients’ lives due to the increased access to mental health and substance use

disorder treatment that the MHPAEA and the implementing rules will provide.

Sincerely,

Elizabeth J. Clark, PhD, ACSWExecutive Director