Docket: EBSA-2009-0010 

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

Equity Act of 2008 

Comment On: EBSA-2009-0010-0001 

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

Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0212 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Karen Love 

Address: 

1310 Prairie Street 

Suite 1080 

Houston, TX, 77002 

Email: tdehoyos@hctx.net 

Phone: 713-368-3285 

Organization: Harris County Healthcare Alliance 

General Comment 

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 

Washington, DC 20210 

ATTENTION: MHPAEA Comments 

To Whom It May Concern: 

Harris County Healthcare Alliance appreciates the opportunity to respond to the 

Request for information regarding the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act (MHPAEA) of 2008 published in the 

Federal Register on April 28, 2009. 

PUBLIC SUBMISSION 

As of: May 28, 2009 

Received: May 27, 2009 

Status: Pending_Post 

Tracking No. 809ba10a 

Comments Due: May 28, 2009

Submission Type: Web
In enacting the MHPAEA, Congress made clear that the goal of this new law was 

to remedy the long history of employers and insurers not providing comparable 

coverage for mental health and substance use treatment versus medical and 

surgical benefits.i In order to achieve this goal the implementing regulations must 

reflect the patient/consumer focus and protective intent of this law and ensure 

access to a meaningful range of evidence-based interventions. 

An overly strict reading of the MHPAEA could thwart its fundamental purpose and 

result in a situation similar to the outcome following enactment of the Mental 

Health Parity Act of 1996 when the vast majority of employers substituted new 

restrictions on access to mental health benefits, thereby evading the spirit of the 

law 

In light of these issues and concerns, our responses to the Request for Information 

are as follows: 

Questions from the Request for Information: 

1. Financial Requirements and Treatment Limitations: 

Do plans currently impose other types of financial requirements or treatment 

limitations on benefits? 

The MHPAEA defines the term "financial requirement" as including deductibles, copayments, coinsurance, and out-of-pocket expenses. The statute likewise defines 

the term "treatment limitation" as including limits on the frequency of treatment, 

number of visits, or days of coverage or other similar limits on the scope or 

duration of treatment." 

But the lists of types of limitations and requirements included in these definitions 

should not be interpreted as the only treatment limitations and financial 

requirements to which parity applies under the new law. Other examples of 

treatment limitations that plans disproportionately use to limit the "scope or 

duration of treatment" for mental health or substance use conditions include the 

following: 

Prior authorization that are applied more frequently and with higher standards for 

approval; Step therapy requirements that force consumers to try a series of 

preferred medications or treatments prior to accessing the recommended 

treatment; Lower provider fees; Limitations on covering specific types of providers; 

Separate deductibles or lifetime limits. 

The MHPAEA regulations should clarify that the parity standard applies to these 

other types of treatment limitations as well. Plans that manage their mental health 

and substance use benefits using these techniques must do so in a 

nondiscriminatory way. 

2. Terms/Provisions in the MHEAPA: 

What terms or provisions require additional clarification to facilitate compliance? 

What specific clarifications would be helpful? 

The following terms and provisions should be clarified in the regulations: 

Parity means equal to or better than—The regulations should emphasize that 
financial requirements or treatment limitations for mental health and substance 

use benefits must be "no more restrictive than" those for medical and surgical 

benefits as stated in the MHPAEA. Impact on state parity laws—Clarification is 

needed to emphasize the continued applicability of state laws that provide for 

greater protection of mental health and substance use benefits. Application of the 

MHPAEA to Medicaid managed care plans—Since the 1996 parity law applied to 

to Medicaid managed care plans the regulations should make clear that the new 

parity law applies to these plans as well. Application of the MHPAEA to CHIP— 

Since the 1996 parity law applied to the Children's Health Insurance Program, the 

new parity which amends the old, should also apply to CHIP. The MHPAEA 

prohibits separate cost sharing and treatment limits—The statute clearly prohibits 

separate deductibles and other cost sharing and treatment limits but this is not 

well understood. 

3. Denials of Reimbursement/Payment for Services: What information, if any, 

regarding the reasons for any denial under the plan of reimbursement or payment 

for services with respect to mental health or substance use disorder benefits is 

currently made available by the plan? To whom is this information currently made 

available and how is it made available? Are there industry standards or best 

practices with respect to this information and communication of this information? 

The MHPAEA requires plans to provide the reasons for any coverage denials with 

respect to mental health or substance use benefits to any current or potential 

enrollee upon request. 

The regulations should 

specify that consumers may request at no charge copies of the documentation the 

plan used to make the coverage determination at issue; set timeframes for 

disclosure of reasons for claims denials; and Outline the process for appealing the 

determinations, including time frames and enforcement mechanisms. 

4. Cost Exemptions: Which aspects of the exemption for increased cost resulting 

from the parity requirement, if any, require additional guidance? Would model 

notices be helpful to facilitate disclosure to Federal agencies, State agencies, and 

participants and beneficiaries regarding a plan's or issuer's election to implement 

the cost exemption? 

MHPAEA provides that plans may be exempt from the law if they can show that 

the parity requirements result in an increase in total costs of coverage by over 2 

percent in the first year and one percent for each subsequent year. 

The regulations should clarify that assessment of whether a plan qualifies for a 

cost exemption must be determined on a retrospective basis and based on real 

experience with increased costs instead of hypothetical costs. 

5. Other issues: The agencies have also stated that they will accept comments on 

any other issues relevant to the development of the MHPAEA regulations. 

Another issue to be addressed is whether only covering mental health medications 

constitutes providing a mental health benefit such that the parity requirements in 

the MHPAEA are triggered. To exclude medications from consideration as mental 

health benefits would imply that the new parity requirements do not apply to this 

essential form of mental health treatment that is one of the therapies most 

analogous to medical and surgical benefits. This result would be inconsistent with 
the intent of the MHPAEA to ensure equity between mental health/substance use 

benefits and medical/surgical benefits."ii 

Thank you for the opportunity to provide comments on this landmark legislation. 

Karen Love 

Executive Director 

Harris County Healthcare Alliance 

1310 Prairie Street 

Suite 1080 

Houston, Texas 77002 

Tele.: (713) 368-3285 

Fax: (713) 368-3938 

www.hchalliance.org 

i H.R. REP. NO. 110-374, pt. 1 (2007) (Educ. & Labor Comm). 

ii H.R. REP. NO. 110-374, pt. 2, Ways and Means Comm., 2007