National Association of State Alcohol and Drug Abuse Directors, Inc.

President 

Flo Stein 

 North Carolina 

First Vice President 

Tori Fernandez Whitney 

 District of Columbia 

Vice President 

for Internal Affairs 

Stephenie Colston 

 Florida 

Vice President 

for Treatment 

Mary McCann 

 Colorado 

Vice President 

for Prevention 

Craig PoVey 

 Utah 

Immediate 

Past President 

Barbara Cimaglio

 Vermont 

President -NDIIC 

Stephenie Colston 

 Florida 

Secretary 

Michael Botticelli 

 Massachusetts 

Treasurer 

Karen M. Carpenter-Palumbo 

 New York 

Regional Directors 

Michael Botticelli, MA 

 Region I 

Karen M. Carpenter-Palumbo, NY 

 Region II 

Ken Batten, VA 

 Region III 

TBD 

 Region IV 

Diana Williams, IN 

 Region V 

Terri L. White, OK 

 Region VI 

Mark Stringer, MO 

 Region VII 

JoAnne Hoesel, ND 

 Region VIII 

Renée Zito , CA 

 Region IX 

Bethany Gadzinski, ID 

 Region X 

Executive Director 

 Robert I. L. Morrison 

May 3, 2010 

Centers for Medicare and Medicaid Services (CMS) 

Department of Health and Human Services (HHS) 

Room 445-G 

Hubert H. Humphrey Building 

200 Independence Avenue, SW 

Washington, D.C. 20201 

File Code: CMS-4140-IFC 

Dear Sir or Madame: 

On behalf of the National Association of State Alcohol and Drug Abuse Directors 

(NASADAD), and our component organizations the National Prevention Network (NPN) 

and National Treatment Network (NTN), I am writing in response to the Interim Final 

Rules (IFR) published on February 2, 2010 by the U.S. Departments of Labor (DOL), 

Treasury and Health and Human Services (HHS) under the Paul Wellstone and Pete 

Domenici Mental Health Parity and Addiction Equity Act of 2008 [MHPAEA). We 

appreciate the opportunity to comment. 

The IFR is consistent with the MHPAEA statute and the goals of Congress: to eliminate 

discrimination in group health plan coverage of mental health and substance use disorder 

benefits and improving access to care. 

The IFR will help to ensure that the MHPAEA is implemented correctly and as Congress 

intended. Additional guidance is needed to help States best inform consumers and the 

broader public about the requirements of the MHPAEA. 

States would benefit from continued guidance from the Departments to ensure greatest 

compliance with the MHPAEA. In particular, although the IFR preamble affirms that the 

MHPAEA does not preempt any State laws except those that would prevent the 

application of the MHPAEA, additional education and outreach is needed to ensure that 

managed care organizations continue to comply with State laws that provide greater 

protections than the MHPAEA. 

The IFR’s inclusion of both quantitative and non-quantitative treatment limitations in the 

MHPAEA parity analysis is fully within the scope of the MHPAEA and is consistent 

with the statute and its legislative history. 

Medical management tools, identified in the IFR as non-quantitative treatment limitations 

(NQTLs), are a fundamental means through which plans limit treatment. NQTLs were 

determined by both Congress and the regulators as a form of treatment limitation as 

defined under the law and hence subject to the purview of the statute and regulations. 

Limiting the scope of the MHPAEA analysis solely to day or visit limits or frequency of 

treatment limits would not achieve the legislation’s intended result of ensuring that 

substance use disorders and mental health benefits are not provided in a more restrictive 

way than benefits for other medical and surgical procedures. 

____________________________________________________________________________________________________________________________________ 

 1025 Connecticut Avenue NW, Suite 605  Washington, DC 20036  (202) 293-0090  Fax: (202) 293-1250  Email: dcoffice@nasadad.org
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In particular, we believe the Rule should explicitly reference that coverage of residential services is required 

under the inpatient benefit. As this issue is examined, a general albeit not perfect parallel can be made between 

substance abuse and mental health residential services and skilled nursing facility (SNF) services. SNF care is 

explicitly included under Medicare Part A coverage and is specifically indicated when a patient requires 

“rehabilitation” services subsequent to an inpatient hospital stay. Massachusetts “Connector” plans include 

coverage for SNF and rehabilitation care on a par with hospitalization. Usually SNF care is short-term (Medicare 

will reimburse care of up to 100 days a year), and it is explicitly not covered as a domiciliary option. 

We understand residential care for mental health and substance use disorder services and SNF does not represent 

an exact parallel. For example, we recognize that a Medicare SNF stay requires inpatient hospital care of at least 

three days – and many clients for whom this type of care is indicated do not receive nor require inpatient care. 

However, we do believe the Rule should explicitly reference that coverage of residential services is required 

under the inpatient benefit. 

The IFR recognizes that excluding certain types of providers from plan networks can significantly limit treatment 

and that plan practices to restrict network access, including setting low reimbursement rates, constitute nonquantitative treatment limitations that must be subject to the MHPAEA analysis. 

Other examples of NQTLs include but are not limited to utilization management; medically necessity criteria; 

“fail first” requirements; prior authorization; and classifying treatment as experimental. 

The Centers for Medicare and Medicaid Services (CMS) should issue guidance clarifying that the IFR applies to 

Medicaid managed care plans. Separate and different parity standards for Medicaid managed care plans could 

lead to a disjointed and inefficient approach to service delivery. 

The MHPAEA statute and its legislative history do not include any distinction between how the law applies to 

group health plans and Medicaid managed care plans. 

The IFR implements the MHPAEA, and Medicaid managed plans must adhere to the MHPAEA. Therefore they 

must comply with the IFR. 

Until CMS affirms that the IFR applies to Medicaid managed care plans, there may be significant confusion as the 

MHPAEA is implemented for Medicaid managed care plans. The MHPAEA is in effect, and guidance is needed 

to ensure the Medicaid managed care plans comply with the requirements of the current law. 

The IFR includes a number of references to “generally recognized independent standards of current medical 

practice” and the need for managed care organizations to use these standards in making decisions about coverage 

for mental health and substance use disorders. 

The substance use disorder treatment field has a body of widely accepted standards of care and evidence-based 

practices for the treatment of substance use disorders. 

In providing additional guidance to plans on standards of care and the scope of services covered in substance use 

disorder treatment benefits, the Departments should adopt these recognized best practices and standards so that 

plan decisions best reflect recognized clinically appropriate standards of care for substance use disorder treatment. 

Specifically, the Departments should:

o Adopt standards developed by experts in the substance use disorder treatment field, such as the 

National Quality Forum’s “National Standards for the Treatment Of Substance Use Conditions” 
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o Explicitly identify these standards and criteria as “generally recognized independent standards of 

current medical practice,” in addition to the Diagnostic and Statistical Manual of Mental 

Disorders, the International Classification of Diseases, and State guidelines, which group health 

plans must use to define the services covered in SUD benefit packages. 

Should the Departments define a scope of services constituting substance use disorder treatment, the levels of care 

identified by the American Society of Addiction Medicine (ASAM) (Early Intervention; Outpatient Treatment; 

Intensive Outpatient/Partial Hospitalization; Residential/Inpatient Treatment; and Medically-Managed Intensive 

Inpatient Treatment) should be included. Including this full continuum will better ensure that people with 

substance use disorders receive the appropriate clinically determined type and level of care. 

The IFR recognizes that high out-of-pocket spending requirements deter individuals from accessing substance use 

disorder services. As a result, the IFR correctly recognized that individuals need a combined mental health and 

substance use disorders and medical deductible to keep out-of-pocket spending requirements at a reasonable level. 

We look forward to working with the Administration as these and other issues unfold. Should you have any 

questions, or require additional information, please do not hesitate to contact me. 

Sincerely, 

Robert Morrison 

Executive Director 

Cc: Flo Stein (North Carolina), NASADAD President