psychosocial criteria, such as the ASAM criteria? for addictions and the
LOCUS criteria3, may be helpful. Similarly, synchronization of behavioral
health case or care management practices with deficit-oriented, “medical
model” case management practices could slow the adoption of recovery-
oriented care management. The President's New Freedom Commission on
Mental Health* has advocated for the adoption of recovery-oriented care
models emphasizing Consumer strengths and empowerment. Examples of
model practices could further clarify the variations in case management
that are permissible.

Please contact us at mhennessey@paritas-health.com if additional information
would be helpful.

Respectfully submitted,

Maureen Hennessey, PhD, CPCC Thomas Goddard, JD, PhD
Principal & Co-owner Principal & Co-owner
ParitasHealth ParitasHealth

2 ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, (Second Edition -
- Revised }, April, 2001,

3 Level of Care Utilization System for Psychiatric and Addiction Services, Adult Version 2010, American
Association of Community Psychiatrists, March 20, 2009.

4 Achieving the Promise: Transforming Mental Health Care in America. The President's New Freedom

Commission on Mental Health, July, 2003.


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As of: May 03, 2010
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PUBLIC SUBMISSION [frostes: ay 03, 20:0,
Comments Due: May 03, 2010)
Submission Type: Web

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-2009-0008-0119
Regulations Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008

Document: IRS-2009-0008-0148
Comment on FR Doc # 2010-02166

Submitter Information

Name: Maureen Theresa Hennessey
Address:

1229 W. 62nd Street

Kansas City, MO, 64113
Email: mhennessey @paritas-health.com
Phone: 816-332-1749
Fax: 816-363-4220
Organization: ParitasHealth

— A
General Comment
We've attached our comments in the pdf file submitted, below.
— ——— —

Attachments

IRS-2009-0008-0148.1: Comment on FR Doc # 2010-02166

https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 5/3/2010


ParitasHealth

May 3, 2010

Our thanks to the Departments of The Treasury, Labor, and Health and Human
Services for the opportunity to comment a second time on the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, also known as
the MHPAEA. We are principals and co-owners of ParitasHealth, a firm providing
consultation and training on mental health parity compliance. Our blog is located at
www. paritas-health.com. As health care consultants with advanced degrees in
psychology and the law, our experience includes development of behavioral health
care networks for most states in our nation, leadership for mental health parity
preparation and administration, and compliance consultation for major health plans
throughout the United States,

The Interim Final Rules issued for the MHPAEA have requested comments on the
scope and definitions of non-quantitative means for management of health and
behavioral health benefits. We provide our comments below under two general
categories, “Scope” and “Non-quantitative Means.”

SCOPE

1. Health plans and payors often provide behavioral health coverage, with
quantitative limits, for services not specifically listed in the Interim Final
Regulations’ six classifications. These behavioral health benefit designs
often include coverage for intensive outpatient programs, partial
hospitalization programs, in-home therapy, and residential treatment.
Guidance would be desirable to ascertain if MHPAEA mandates coverage of
these services. If MHPAEA does mandate such coverage, a “care-
continuum crosswalk” specifying the equivalent medical services would
aid plans and payors with uniform compliance across the care
continuum. For example, such a “crosswalk” might identify that outpatient
facility care could be considered the medical equivalent to intensive
outpatient care, and home health visits could be the medical equivalent of in-
home psychiatric nursing visits or in-home psychotherapy visits. The
“crosswalk” would provide guidance for plans seeking to provide benefits for
a continuum of behavioral health services, comparable to the continuum of
other, covered health services.

2. Some states mandate coverage for services, but with a day or dollar cap. In
some instances, the mandated services are outside the six classifications
referenced in the Interim Final Rules. The question that we have is whether
those state caps will still stand, given MHPAEA. For example, if a state
mandates coverage for residential care for substance abuse or mental health
conditions, with a quantitative (dollar or day limit} cap, will the payor now
be required to offer a residential benefit with a less stringent cap? Examples
of scope and duration of services not referenced in the six classifications,

1229 W. 62nd Street, Kansas City, MO 64113 * 816.332.1749 * http://paritas-health.com


but referenced in state parity mandates, could promote consistent
compliance with the MHPAEA.

NON-QUANTIT; N.

1. Some plans are introducing Value Based Insurance Design (VBID) for select
medical conditions, such as diabetes and hypertension. VBID has been
defined as “A methodology for identifying clinically beneficial
screenings, lifestyle interventions, medications, immunizations,
diagnostic tests and procedures, and treatments for which co-
payments or coinsurance should be adjusted or eliminated due to their
high value and effectiveness when prescribed for particular
clinical conditions.” A fundamental purpose of VBID is to decrease
financial barriers to purchasing “high value” services, with the goal of
improving patient adherence and avoiding higher, future medical costs. Such
plans often offer patients lower copays for services and medications,
contingent upon participation in, for example, a disease management
program. Ifa plan offers VBID for one or more medical conditions, are
they obligated under MHPAEA to offer such a benefit for one or more
behavioral health conditions? Additional examples using VBID could
provide further clarification.

2, Further guidance is requested regarding the role of Employee Assistance
Plans (“EAPs”) as gatekeepers or gateways to care. The Interim Final Rules
specify that requiring a consumer to exhaust the EAP benefit before using
his/her major medical program's behavioral health benefits would be a
violation, unless a similar process applies for medical/surgical benefits. But
what if notification, or screening, by the EAP, is required? If a patient's plan
doesn’t require the patient to contact their PCP before non-emergent care,
would requiring a patient to call their EAP, before receiving non-emergent
behavioral health care, be considered a violation? The current rules aren't
clear about EAP notification or telephonic or face-to-face screening by the
EAP. These are common practices, particularly among self-insured
companies, Additional examples regarding EAPs could promote compliance.

3. Finally, we would like to comment regarding non-quantitative tools and
practices used to manage behavioral health care. We are concerned that
synchronization of behavioral health medical necessity criteria with other
health medical necessity criteria will result in less emphasis being placed on
psychosocial factors as discharge determinants. Insufficient emphasis on
psychosocial criteria may result in increasing re-admissions, to the detriment
of the Member and the plan or payor. Examples of tools that address

1 Fendrick, A. Mark, “Value-Based Insurance Design: Returning Health and Wellness to the Health
Care Cost Debate,” presentation at http:;//www.nypsystem.org/pdf/Mark Fendrick.pdf, University of
Michigan Center for Value-Based Insurance Design (http://www.vbidcenter.org/).