Docket: IRS-2009-0008 

Request for Information for Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 

2008 

Comment On: IRS-2009-0008-0001 

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

Equity Act of 2008 

Document: IRS-2009-0008-0076 

Comment on FR Doc # E9-09629 

Submitter Information 

Name: Matthew Brams, MD 

Address: 

Houston, TX, 

Organization: Interface EAP 

General Comment 

1. Clarify that Medical Management of MH/SA can be handled differently 

than medical/surgical benefits. Most psychiatric disorders have a low inter-rater 

reliability with many subjective symptoms and there are wide variations in the way 

psychiatric patients manifest their symptoms leading to different diagnoses, 

prognoses, and treatments. A diagnosis only will not determine the type, 

frequency, or intensity of treatment needed, therefore, concurrent management of 

individual cases is warranted to ensure optimal and appropriate care. One cannot 

run a diagnostic test or x-ray for a mental health problem. Furthermore, the 

appropriate course of treatment for two different patients with the same diagnosis 

may vary greatly. This is why there are not DRGs for mental health diagnoses. 

Need clarification in the law to state that medical management for MH/SA benefits 

can be done separately without regard to parity for the medical management of 

medical/surgical benefits. It needs to be clearly stated that certain requirements 

such as precertification or concurrent review can be utilized for MH/SA medmanagement even if the plan does not require the same for medical/surgical 

benefits. Again, the treatment of these conditions is very different and the 

management of the care must also be handled differently. No language in the 

parity law states that med-management provisions must be applied the same as 

for medical/surgical benefits. 

2. Clarify whether EAPs are included in the entities that are required to 

comply with parity. EAPs address many personal issues for employees and help

PUBLIC SUBMISSION 

As of: May 28, 2009 

Tracking No. 809b9b0a 

Comments Due: May 28, 2009
improve productivity for employers. Some are related to mental health issues but 

many are related to legal, financial, work/life, etc. If EAPs were somehow required 

to comply with the parity mandates, it would end the vital role that EAPs play 

today for employers and their employees. 

3. Clarify whether separate, but equal deductibles and out-of-pocket 

maximums for MH/SA and medical/surgical benefits can be applied. It is 

understood that the MH/SA benefit cannot have a higher deductible or any 

limitations more restrictive than those on the medical/surgical benefit. It is not 

clear whether each benefit could have separate deductibles and out-of-pocket 

maximums that are equal or must only one deductible and out-of-pocket maximum 

be applied to both benefits. 

4. Clarify HIPAA preemption standard. Local governmental entities must 

comply with the state laws regarding MH/SA. How will it be determined whether 

the state law preempts the federal law? Will the state law be preempted if it has 

limitations within their regulations? 

5. Clarify that employer health plans can chose which, if any, MH/SA 

conditions they want to cover. Nowhere in the parity law does it state that any 

MH/SA benefits must be provided by a health plan. Furthermore, the parity law 

does not state that certain MH/SA conditions must be covered if the health plan 

does opt to cover any MH/SA conditions. 

6. Clarify “no more restrictive than the predominant financial requirement 

(or treatment limitation) applied to substantially all medical and surgical benefits.” 

Does this mean that outpatient MH/SA must be in parity with the outpatient 

medical/surgical portion of the benefit or to the complete medical/surgical benefit? 

How are the Out-of-Network benefits for MH/SA to be compared to the Out-ofNetwork medical/surgical benefits? 

7. Clarify the disclosure of medical necessity criteria requirement. Can 

this be regulated in the same way as current state laws and DOL requirements? 

8. Clarify the employer cost exemption process. We are not 

recommending this to any of our groups, but this will be examined as a possibility 

by groups. What is the process the employer would need to apply for the cost 

exemption? Where would they apply? What time frames would be involved? 

9. Clarify that employers who act in good faith with this new legislation will 

not be penalized if the law is later clarified that would require the employer to 

modify their plan to be in compliance. Also, state that health plans may wait until 

their next annual renewal to make any changes required after the Regulatory 

Guidance is issued if the initial plan renewal was before the Regulatory Guidance 

was issued. 

10. Clarify coverage of evidence-based treatments. Current 

medical/surgical benefits do not require that all evidence-based treatments be 

covered per medical condition and that the plan may specify which evidence-based 

treatments will be covered. The same should be clarified for MH/SA under parity. 

The cost impact to plans would be significant if all evidence-based treatments are 
mandated to have coverage, for medical/surgical and/or MH/SA.