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-0247 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Betty Simmonds 

Address: 

Bldg 3, Ste 200, 2101 N Front Street 

Harrisburg, PA, 17110-1063 

Email: betty@paproviders.org 

Phone: 717-364-3280 

Organization: PA Community Providers Association 

General Comment 

Office of Health Plan Standards and Compliance Assistance 

Employee Benefits Security Administration 

Room N-5653 

US Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Attention: MHPAEA Comments 

The Pennsylvania Community Providers Association (PCPA) is a trade 

association representing more than 200 community based agencies across 

Pennsylvania that provide mental health, intellectual disability and addiction 

services for children and adults. PCPA represents providers on legislative and 

administrative matters, serves as a forum for the exchange of information and 

experience and serves as a point of contact with other related statewide 

organizations. PCPA members provide services to almost one million 

Pennsylvanians each year. 

PUBLIC SUBMISSION 

As of: May 28, 2009 

Received: May 28, 2009 

Status: Pending_Post 

Tracking No. 809bc4d3 

Comments Due: May 28, 2009

Submission Type: Web
PCPA members and those they serve appreciate Congressional efforts to ensure 

that mental health and substance use disorder services and supports are covered 

adequately by insurance through the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act of 2008 (Act). Too often there is a financial 

barrier that prevents access to needed services. Lack of coverage exacerbates 

reluctance to seek services due to issues of stigma and fear. 

PCPA is concerned that definitions of mental health and substance use disorder 

benefits may exclude services and supports that have proven effective, but present 

very differently from the general framework of treatments most understood by 

insurers. 

• Services such as psychiatric rehabilitative services, peer support, 

mobile therapies and treatment should be covered. 

• Access to a full array of medications is needed. 

• Community standards of care and service, as well as evidence-based 

practices, should be followed. 

• Treatment, duration of treatment, and new treatments should be driven 

by an independent panel of mental health and substance use disorder experts, 

rather than individuals employed or engaged by insurers. 

• Covered services should not be static. As with medical/surgical 

services, new and innovative services and supports must be encouraged and 

covered by the Act. 

Medical necessity criteria must be made available so that all know what to 

expect. 

• Narrow medical necessity criteria can, and often does, limit and 

exclude needed services, particularly services that are costly. 

• Language in regulation must be carefully crafted to minimize denials of 

services based on overly stringent medical necessity determinations. 

• It is not sufficient to only make available the reason for denials. The 

information used to make the determination should also be provided. 

• A timely and responsive grievance and appeal process must be readily 

accessible. 

Other means that are often used to limit access to services must be addressed. 

• Fail first policies should not be used. The appropriate services, 

determined by the provider/practitioner and the individual, should be accessible 

when needed. 

• Utilization management must be done by persons with expertise in the 

respective behavioral health services. A timely independent review process for 

denials must be instituted. 

• Where state law and regulations are more stringent than federal law 

and regulations, state requirements should prevail. 

Limitation of network providers is also a means of excluding real coverage for 

services. 

• Requirements must include language related to adequacy of provider 

networks based on geographic location, services provided, and wait time for 

services. 

• Community providers of behavioral health services (mental health and 
substance use disorder) must be included in the networks to provide the broad 

array of services needed by individuals. 

• For those instances when a network provider is not readily available for 

the needed service or support, reasonable access to out-of-network providers 

must also be afforded. The process must not be so onerous as to actively 

discourage individuals from seeking needed services from an out-of-network 

provider. Nor can it be a prior authorization process for which services are never 

authorized. 

• A mechanism is needed for expedited appeals in urgent and 

emergency situations. Coverage should not be denied when the urgency of the 

situation makes prior approval infeasible. 

Low rates offered to providers can also effectively limit coverage. Rates must be 

fair and competitive so that qualified mental health and substance use disorder 

service providers can participate in provider networks. 

The language of insurance is very confusing. Standard notification letters, denial 

letters, and other types of communication should be developed to minimize 

confusing language and make the information conveyed clear and understandable. 

As more and more research supports the importance of treatment of mental health 

and substance use disorders to the physical health of the person, there are 

provisions in the Act that allow for exemption from coverage. It may be impossible 

for very small employers to provide health care coverage, but if coverage is 

available, then coverage for behavioral health services should be included. Overall 

costs should be less if the whole person is served, rather than treating only 

physical health issues that may not be effectively treated if behavioral health 

issues impede full participation in the treatment regimen. Small employers could 

continue exemption from coverage for behavioral health services for years to the 

detriment of their employees. 

Thank you for this opportunity to comment on the Act and we look forward to real 

equity and parity for physical health, mental health, and substance use disorder 

service coverage. 

Sincerely, 

George J. Kimes 

Executive Director