We’ve been there. We can help. 

730 N. Franklin Street, Suite 501 ● Chicago, IL 60654-7225 

(312) 642-0049 ● Toll-Free (800) 826-3632 ● Fax (312) 642-7243 ● www.DBSAlliance.org

May 28, 2009 

Internal Revenue Service 

U.S. Department of the Treasury 

Employee Benefits Security Administration 

U.S. Department of Labor 

Centers for Medicare & Medicaid Services 

U.S. Department of Health and Human Services 

Re: Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 (published in 74 Fed. Reg.19155 et seq.) 

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

To the Departments: 

The Depression and Bipolar Support Alliance (DBSA) welcomes the opportunity to respond to the 

request for information as the departments begin the rulemaking process on the Paul Wellstone and 

Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, also known as MHPAEA. 

DBSA feels it is important that the departments keep as their main focus the clear and 

straightforward assessment of Congressional intent for this law. The clear intent of the law to 

require group health plans with more than 50 employees to provide benefits coverage for mental 

health and substance use services on an equal footing with medical surgical benefits, or in simple 

terms, parity. There will inevitably be differences in interpretation between existing rules and 

regulations, and disputes over how to implement particular aspects of the law. DBSA feels that by 

adhering closely to the letter and spirit of the law, as evidenced by Congressional intent, the 

departments will ensure rules and regulations that satisfied members of the public, and the Congress. 

We address several of the questions from the Request for Information below: 

Comments Regarding Economic Analysis, Paperwork Reduction Act and Regulatory 

Flexibility Act 

Some form of parity legislation exists in more than 40 states; limited parity has been in effect in 

Federal law since 1996, including several “Sunset provision” extensions. DBSA, despite a 

serious attempt to find instances where any of the laws had a deleterious economic or paperwork 
We’ve been there. We can help. 

730 N. Franklin Street, Suite 501 ● Chicago, IL 60654-7225 

(312) 642-0049 ● Toll-Free (800) 826-3632 ● Fax (312) 642-7243 ● www.DBSAlliance.org

burden impact, on employers (large or small) or health insurers, has been unable to substantiate 

any such impact. With the current widespread adoption of electronic health records and 

electronic billing, DBSA anticipates that any economic impact will be minimal, to insurers or 

employers. We would urge that any claims of excessive cost or paperwork burden be rigorously 

examined, and that appropriate historical data be provided by those asserting such high burden or 

cost. 

Do plans currently impose other types of financial requirements or treatment limitations 

on benefits? How do plans currently apply financial requirements or treatment 

limitations to (1) medical and surgical benefits and (2) mental health and substance use 

disorder benefits? Are these requirements or limitations applied differently to both 

classes of benefits? Do plans currently vary coverage levels within each class of 

benefits?

It was the intent of Congress that separate pools of deductibles for mental health and medical and 

surgical benefits be construed as financial discrimination. The MHPAEA states that there are to 

be “no separate cost sharing requirements that are applicable only with respect to mental health 

or substance use disorder benefits.” For a plan to require an individual to pay an out of pocket 

deductible for medical and surgical benefits and then a separate deductible for mental health 

benefits is not equitable and would tend to pose a significant barrier to treatment for many 

individuals. Separate but equal deductibles and out of pocket maximums are discriminatory and 

should be prohibited. 

What terms or provisions require additional clarification to facilitate compliance? What 

specific clarifications would be helpful?

Several states, Washington, to name one, have broader mandates than MHPAEA. DBSA believes 

that the MHPAEA should serve as a floor on benefits, not as a ceiling. States with broader mandates 

should not have their laws pre-empted by MHPAEA, while MHPAEA requirements should be seen 

as “mandatory minimums”. In no way should MHPAEA become an impediment to improving 

services for mental health or substance use disorders. We believe the Departments should seek 

information from the various states as to their individual parity laws, along with states’ assessments 

of the impact of these parity laws, especially their impact on costs. Organizations like the National 

Association of Insurance Commissioners (NAIC) may also be consulted to help determine the best 

way to integrate federal and state law in a manner consistent with Congressional intent in 

MHPAEA. 

Network design, and especially “phantom networks” of providers have proven to be significant 

barriers to individuals attempting to access appropriate services. Serious consideration needs to 

be given to allowing maximum flexibility for individuals to access out of network providers 

when insurers are unable to provide access through their own network. 
We’ve been there. We can help. 

730 N. Franklin Street, Suite 501 ● Chicago, IL 60654-7225 

(312) 642-0049 ● Toll-Free (800) 826-3632 ● Fax (312) 642-7243 ● www.DBSAlliance.org

Some thought needs to be given to the inclusion of the various mental health specialties as part 

of the provider network. Having a wider range of provider specialties and levels of service 

available to persons needing services can lead to improved outcomes as well as reduce 

dependence on the most expensive services, typically inpatient hospitalization. 

What information, if any, regarding the reasons for any denial under the plan (or 

coverage) of reimbursement or payment for services with respect to mental health or 

substance use disorder benefits is currently made available by the plan? To whom is this 

information currently made available and how is it made available? Are there industry 

standards or best practices with respect to this information and communication of this 

information?

Service denials are often delivered in cryptic language that even professionals don't always 

understand. Explanations of service denial should be provided in plain language, with a clear 

statement as to why a particular service was deemed inappropriate. There should be clear 

directions, again in plain language, on how individuals may access any appeals process that they 

are entitled to under their plan coverage. 

Which aspects of the increased cost exemption, if any, require additional guidance? 

Would model notices be helpful to facilitate disclosure to Federal agencies, State 

agencies, and participants and beneficiaries regarding a plan’s or issuer’s election to 

implement the cost exemption?

While the potential for increased cost exemption may be required in some instances, the regulations 

should be based on requiring thorough documentation of such increased costs. The 1996 law 

provides good guidance to the departments for this part of the regulations. Model notices would be 

most helpful, and should be standardized. 

DBSA appreciates the opportunity to comment on the Departments’ Request for Information, and 

we thank you for considering our views. We stand ready to be of assistance in the next steps of the 

implementation of the MHPAEA. 

Sincerely yours,

Peter Ashenden, President/CEO 

Depression and Bipolar Support Alliance