242 Green St. Gardner, MA 01440 

April 29, 2010 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Room 445-G, Hubert H. Humphrey Building 

200 Independence Ave., SW 

Washington, D. C. 20201 

Re: File Code: CMS-4140-IFC 

Dear Sirs: 

On behalf of the Heywood Hospital, I am offering comments relative to File Code CMS-4140-

IFC; Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health and 

Addiction Equity Act of 2008. Heywood Hospital has 32 inpatient mental health beds and 4 

partial hospitalization beds. We admit over 1,100 patients on an annual basis. 

We think these regulations are extremely important and hope they are officially promulgated. 

In Massachusetts, we have extensive experience with Parity Laws, having passed the first 

Parity Law in 2000; and then more recently an expansion of that law in 2008. The passage of 

these laws has helped equalize the insurance treatment for behavioral health, primarily be 

removing arbitrary day and dollar benefit limitations for certain conditions. However, these 

laws have done little to nothing towards reducing the inordinate micro-management and 

oversight by Carve-Out firms. There is heavy utilization of Carve-Out firms in Massachusetts, 

both in the public and private sectors. The oversight is far more rigorous for behavioral health 

than it is for medical/surgical services in the areas of Pre-Admission Screenings; Concurrent 

Reviews; and the application of Medical Necessity Standards. Hospitals and clinicians 

continually struggle to get Carve-Out firms to approve services that the attending clinicians 

believe are medically necessary. Evidence of the difficulties our patients and clinicians 

experience in this regard is demonstrated by the fact that consistently behavioral health is the 

most appealed health service to our Massachusetts Office of Patient Protection, usually at least 

double the next highest appealed condition; see www.mass.gov/dph/opp. Providers are 

constantly questioned and micro-managed by Carve-Out reviewers as to the medical necessity 

of a given behavioral health service. In Massachusetts, we believe the scrutiny for physical 

health is no where near the level of scrutiny for behavioral health. Indeed, the MABHS has 

filed legislation, S. 482 and H.1079, which would balance the application of medical necessity 

determinations by providing more authority for the attending clinician, verses the Carve-Out 

reviewer. 

Given the above situation we believe the proposed federal regulations, particularly in the area 

of “non quantitative” treatment limits, are vitally important and must be maintained in the 

final regulations. Our understanding of the non quantitative proposed rule is that treatment 

limitations can be no more stringent for mental health or substance abuse than they can be for 
medical/surgical benefits. Our Massachusetts experiences would lead us to believe this 

provision is critical towards implementing true Parity-because we have seen through nearly 

ten years of Parity Laws that removal of day and dollar limits essentially does not lead to 

Parity if the behavioral health services are going to be more rigorously managed, scrutinized 

and denied by Carve-Out firms. Parity with medical/surgical benefit management would be a 

major step forward in providing better access to needed services for the patients we serve and 

in essence would help lead towards true Parity, which we believe the Congress intended. We 

hope that the federal agencies adhere to this language in the final regulations; for without such 

a provision it is difficult, if not impossible to achieve true Parity for mental health and 

substance abuse services. 

We also request that there be clarification in the final regulations that the plans provide all 

levels of essential behavioral health services, just as they do for medical/surgical services. In 

order to have Parity, the scope of services should be comparable for behavioral health and 

medical surgical services. 

I appreciate the opportunity to offer these comments and stand ready to answer any questions 

or provide any further details you may need. 

Sincerely, 

Jon Marcinkiewicz, MA CAGS 

Therapeutic Leader 

Mental Health Unit 

Mar.ja@heywood.org 

(978) 630-6377