May 3, 2010

Submitted through Federal eRulemaking Portal

The Honorable Hilda Solis

Secretary of Labor

200 Constitution Avenue, NW

Washington, DC 20210

The Honorable Kathleen Sebellius

Secretary of Health and Human Services

7500 Security Boulevard,

Baltimore, MD 21244-1850

The Honorable Timothy Geithner

Secretary of Treasury

1111 Constitution Ave., NW 

Washington, DC 20224

Attention: MHPAEA Interim Final Rule Comments

RIN 1210-AB30 (EBSA)

CMS-4140-IFC (HHS)

REG-120692-09 (Treasury)

Dear Secretaries Solis, Sebellius and Geithner,

The National Committee for Quality Assurance (NCQA)—a leading evaluator of health care 

quality and accreditor of health plans—commends DOL, HHS, and Treasury on their work in 

drafting the Interim Final Rule relating to the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act of 2008.

NCQA has a broad interest in the quality of mental health coverage Americans receive. We 

require reporting of several mental and behavioral health measures in the HEDIS data set. For six

years now, we have served as an accreditor of Managed Behavioral Health Organizations 

(MBHOs), requiring that members have adequate access to mental health providers and that the 

accredited MBHO document a utilization review process that is consistent and based on clinical 

evidence. We also emphasize that many chronic illnesses are behavioral conditions, and that 

many chronic medical conditions are exacerbated by lack of behavioral health treatment or 

management. Evidence shows that serious mental health conditions that go untreated can lead to 

poor physical and mental health, lower worker productivity, higher absenteeism, and eventually 

higher health care costs.

Plans that provide both medical and mental health benefits should enforce “nonquantitative” 

coverage limitations using the best evidence available in a transparent process. As the IFR 

describes, nonquantitative coverage limitations may refer to “medical management standards; 
prescription drug formulary design; standards for provider admission to participate in network; 

determination of usual, customary, and reasonable amounts...”

With particular regard to medical management standards—or utilization review—each medical 

or mental health intervention, treatment, or office visit is unique, and there is no practicable way 

to compare whether a single coverage decision to remit payment for a mental health event is 

arrived at in a fashion that is no more restrictive than a corresponding medical or surgical one. 

The Departments clearly acknowledge this in providing for an exception to direct parity 

requirements: “...to the extent that recognized clinically appropriate standards of care may 

permit a difference [between nonquantitative restrictions applied to medical and mental health 

benefits].”

We submit that this narrow exception should be expanded into a safe harbor for plans that use a 

documented utilization management review process that

is presided over by a mental health practitioner;

requires that coverage decisions be objectively based on clinical evidence where possible;

is applied consistently;

and renders timely decisions that are subject to appeal by members and practitioners.

The Departments should work with mental health experts and plan administrators to clearly 

define criteria that a mental health utilization review process would have to meet in order to 

achieve the safe harbor, along the above lines. A review of NCQA’s Standards and Guidelines 

for the Accreditation of Managed Behavioral Health Organization may be helpful. Plans should

then be required to demonstrate compliance to the satisfaction of the Departments with these 

written standards, or be certified as having done so.

This would ensure that nonquantitative coverage limitations are applied in an evidence based 

manner, not capriciously in order to limit mental health utilization. This achieves the intent of the 

law and such a process would ensure the outcome described in Example 4 under (c)(4) of the 

amended rules.

We thank you for the opportunity to comment, and stand ready to discuss any of the above 

recommendations with the Departments, or assist in any other way we are able.

Sincerely,

Margaret E. O’Kane

President