May 27, 2009 

Office of Health Plan Standards and Compliance Assistance 

Employee Benefits Security Administration 

Room N-5653 

U.S. Department of Labor 

200 Constitution Avenue, NW. 

Washington, DC 20210 

RE: MHPAEA Comments

To Whom It May Concern: 

The National Alliance on Mental Illness of Massachusetts (NAMI Mass) is a nonprofit grassroots advocacy, education and support organization. Our mission is to support individuals 

with mental illness and their families; advocate for nondiscriminatory and equitable federal, 

state and private-sector policies; and educate the public to eliminate the pervasive stigma 

surrounding mental illness. 

NAMI Mass, with 23 local affiliates and over 2500 members, is a statewide organization 

comprised of individuals with mental illness, family members and others in the mental health 

community. 

We have the following comments regarding the Mental Health Parity and Addiction Equity 

Act of 2008. 

Questions and comments will be numbered as set out in the Federal Register. 

1. Do plans apply financial requirements or treatment limitations differently to (1) medical 

and surgical benefits and (2) mental health and substance use disorder benefits? 

A1. One financial problem is that the reimbursement rates for mental health outpatient 

therapy are much less than the rates for medical outpatient care. NAMI Mass currently is in 

a group plan with Blue Cross Blue Shield of Massachusetts (BCBS MA) to provide medical 

and behavioral health benefits to its employees. Based on the experience of one NAMI 

employee, we know that BCBS MA pays $50 for a 45 minute outpatient visit (and the patient 

pays $25 co-pay) for a total of $75 payment. This is a good example of how mental health 

care is undervalued and how medical care is more valued and hence receives a higher 

reimbursement rate. 
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Patient co-pays are more expensive for some psychiatric medications than other 

prescription medications. For example, one NAMI Mass employee notes that the copay for Effexor (an antidepressant, also prescribed for generalized anxiety disorder) 

is $50, more than other prescription medications. 

Some medications prescribed for mental health patients need to be followed with 

routine blood work. One patient we know of was on such a medication, which was 

covered by the health insurance plan, but the necessary blood work had to be paid 

out of pocket by the patient. We have never heard of blood work for medical care 

that was not covered. This is another example of the disparity between financial 

coverage for behavioral health and medical health. 

Another issue of concern is the recent closing of adult psychiatric hospital beds and 

the closing of substance abuse beds at Cambridge Health Alliance here in 

Cambridge, Massachusetts. The reason for closing the psychiatric beds and the 

substance abuse beds is because the reimbursement rate for those beds is much 

lower than the reimbursement for other hospital beds. Many mental health patients 

are on public assistance. State agencies have confirmed that 61% of the hospital's 

payer mix for psychiatric and substance abuse hospital days was from MassHealth 

(Massachusetts’ version of Medicaid), Managed Care Organizations within 

MassHealth and uninsured patients. Many private facilities do not accept uninsured 

patients or patients covered by these health plans. With the beds closed, NAMI 

Mass is concerned that patients living in the hospital's network area will have 

nowhere to go. 

What terms or provisions require additional clarification to facilitate compliance? 

What specific clarifications would be helpful?

A2. We urge the federal government to issue an explanatory bulletin “enforcement.” 

Our experience with HIPAA (Health Insurance Portability and Accountability Act of 

1996) tells us the enforcement will be a huge issue; referring people to the Office for 

Civil Rights web site for “enforcement” is very insufficient and people are very 

frustrated about where to go when they feel a violation of HIPAA exists. 

The language in the federal parity law says that the U.S. Department of Labor, Health 

and Human Services and Treasury will continue to coordinate enforcement of the 

federal mental health parity requirements. We understand that regulations will be 

promulgated but we strongly suggest that “enforcement” of this new parity law be 

very specific. This law will cover millions of people and thousands of employers. 

Knowing with specificity where to go with a complaint and how to get the complaint 

filed so someone will actually look into the issue will be critically important. 

 
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5. Is the out-of-network coverage for mental health and substance use disorder 

benefits different than out-of-network coverage provided for medical and surgical 

benefits?

A5. Often mental health patients are assigned to an out-of-network plan or an entity 

contracting with the health plan. In Massachusetts, under these conditions, many 

behavioral health services were not being provided adequately. For example, 

patients were assigned to mental health providers who were a great distance from 

their homes, essentially depriving them of needed health care. Massachusetts 

passed a Mental Health Parity Law which corrects this injustice. Massachusetts 

agencies periodically publish bulletins which provide clarification of state statutes. 

Consequently, in 2002, the Massachusetts Division of Insurance issued a bulletin 

explaining the Massachusetts Mental Health Parity Law. The bulletin explained that 

“[c]arriers contracting with another entity ... for the administration or provision of 

behavioral health services remain responsible for: (1) ensuring that services provided 

or coordinated by such entity comply with the provisions of all relevant statutes; and 

(2) taking steps to coordinate care.”1

Additionally, the Massachusetts bulletin provides that: 

“For carriers that provide benefits through a network or through participating 

providers, adequate access means at a minimum that: 

• the network contains all mandated provider types. 

• the network providers offer the full range of mandated services, including 

specific treatment modalities appropriate for all ages of patients and all types 

of covered mental conditions. (The mental health parity law specifically states 

that there must be available a range of outpatient, intermediate and inpatient 

mental health treatment.) 

• there are sufficient numbers of providers available in the network so that no 

patient must wait a medically inappropriate amount of time to receive care for 

acute conditions. 

• care is being delivered promptly and appropriately and that insureds are being 

provided adequate access as required by law. 

• provider directories containing the names of all behavioral health providers in 

the carriers’ network.”2

A copy of the Massachusetts Division of Insurance-2002-07 Mental Health Benefits 

dated February 15, 2002 is attached. We urge that the federal government use this 

bulletin as a model to issue clarification that any behavioral health networks must 

comply with the new law, and among other things, guarantee a robust network that 

includes all provider types. 
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We anticipate problems with “out-of-network” coverage unless specific steps, such as 

we suggest, are followed. 

6. Which aspects of the increased cost exemption, if any, require additional 

guidance?

A6. The provision which allows a plan an exemption for one year, if certain costs 

apply, needs additional clarification. This potentially is a major exemption from the 

law. The Department of Labor, Internal Revenue Service, and Centers for Medicare 

and Medicaid Services need to provide further explanation and set forth mechanisms 

to monitor such exemptions. How will these agencies be assured that the health 

insurance plan is in compliance? Reporting procedures must be detailed. A policy 

and rules need to be established through which individuals can request information. 

 *** 

Thank you for the opportunity to comment. 

Sincerely, 

Laurie Martinelli Chris Previtera, JD 

Executive Director NAMI Volunteer 

Cc: NAMI National office 

Enclosure 

 1

 Massachusetts Division Of Insurance-2002-07 Mental Health Benefits dated February 15, 2002 

2

 Massachusetts Division Of Insurance-2002-07 Mental Health Benefits dated February 15, 2002