Stephen C. McCaffrey, JD
President
Chief Executive Officer

MHA in Alicn County
MLLA of Blackford County
MITA of Boone County
MHA of Cass County
MHA of Clark County
MHA of Clay County
MHA of Clinton County
MHA of Daviess County
MHA of Decatur County
MHA of DeKalb County
MHA of Delaware County
MHA of Dubois County
MILA of Elkhart County
MLA of Floyd County
MIIA of Franklin County
MHA of Fulton County
MHA of Gibson County
MHA of Greater Indianapolis
MHA of Greene County
MBA of Hanulton County
MHA of Hancock County
MHA of Hendricks County
MHA of Henry County
MHA of Howard County
MHA of Jackson County
MHA of Jay County
MHA of Jeffersan County
MHA of Johnson County
MHA of Knox County
MLIA of Kosciusko County
MITA of Lake County
MIA of LaPorte County
MHA of Lawrence County
MHA of Marshall County
MHA of Monroe County
MHA of Morgan County
MHA of Parke County
MHA of Perry County
MHA of Porter County
MHA of Putnam County
MHA of Randolph County
MHA of Rush County
MLIA of St Joseph County
MIIA of Spencer County
MHA of Steuben County
MHA of Tippecanoe County
MHA of Union County
MHA of Vanderburgh County
MHA of Vigo County.
MHA of Wabash County
MHA of Warrick County
MIA of Wayne Count

MHA of Wells County
MHA of Whre County

M! tA

Mental | | America

whet

Services must be available to maintain or restore function and to
prevent or ameliorate medical conditions in addition to treating
injuries or illnesses; and
iii. Cost elfectiveness does not necessarily mean lowest cost.
The regulations should require plans to do the following:
e Set timeframes for disclosure of medical necessity criteria;
Detail appeal and enforcement mechanisms,
Make available to beneficiaries, upon request, the standards used to
determine whether the criteria for medical necessity (e.g., standard of
practice, strength of the evidence base, and definition of medical
conditions) with regard to mental health and substance use treatments;
and
« Make available to beneticiaries, upon request, the standards used to
assess whether the medical necessity criteria have been met for
medical and surgical benefits.

4. 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
eurrently 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

specily 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 entorcement mechanisms.

www.mentalhealthamericaindiana.net

1431 North Delaware Sueet + Indianapolis, IN 46202 + 317.638.3501 + 1.800.555, MIAL « F:317.638,3540


Stephen C. McCaffrey, JD
President
Chief Executive Officer

MLIA in Allen County
MITA of Blackford County
MIIA of Boone County
MHA of Cass County
MHA of Clark County
MHA of Clay County
MHA of Clinton County
MHA of Daviess County
MHA of Decatur County
MHA of DeKalb County
MHA of Delaware County
MHA of DuBois County
MITA of Elkhart County
MITA of Floyd County
MHA of Franklin County
MHA of Fulton County
MHA of Gibson County
MHA of Greater Indianapolis
MHA of Greene County
MHA of Hamilton County
MHA of Hancock County
MHA of Hendricks County
MHA of Ilenry County
MHA of Howard County
MHA of Jackson County
MHA of Jay County
MHA of Jefferson County
MHA of Johnson County
MUA of Knox County
MITA of Kosciusko County
MITA of Lake County
MHA of LaPorte County
MHA of Lawrence County
MHA of Marshall County
MHA of Monroe County
MHA of Morgan County
MHA of Parke County
MHA of Perry County
MHA of Porter County
MHA of Putnam County
MHA of Randolph County
MHA of Rush County
MILA of St Joseph County
MITA of Spencer County
MHA of Steuben County
MHA of Tippecanoe County
MHA of Union County
MHA of Vanderburgh County
MHA of Vigo County
MHA of Wabash County
MHA of Warrick County
MIIA of Wayne County
MHA of Wells County
MHA of White County

MH Aad

Mental i America

Hawion

© 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.

e 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.

e 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. Medical Necessity:

What information, if any, regarding the criteria for medical necessity
determinations made under the plan with respect to mental health or
substance use disorder benefits is currently made available by the plan?
To whom is this infurmation currently made available and how is it
made available? Are there industry standards or best practices with
respect to this informativo and communication of this information?

MHPARA requires plans to provide the criteria they use to make medical
necessity determinations to any current or potential enrollee or contracting
provider upon request.

Most medical necessity standards used by the health plans seem to focus on
the following criteria:

i. customary standard of practice whether the treatment accords with

prolessional standards of practice;

ii. evidence-based whether there is sufficient evidence to demonstrate
effectiveness:

iii, medical service whether the treatment is considered medical as
opposed to social or custodial; and

jv. cost whether the treatment is considered cost-effective by the
insurer [3]

The following additional clarifications would make this criteria better:

i. Evidence from national experts should be considered if peer-
reviewed literature is not available;

www.mentalhealthamericaindiana.net

1431 North Delaware Street + Indianapolis, IN 46202 » 317.638.3501 = 1.800.555.MHAI + F.317.638.3540


M A
| | yx i
Mental izatii America

Stephen C. McCaffrey, JD crandhiens:

President
Chief Executive Officer

___ 5. Out-of-Network Coverage: To gather more information on the
MUA in Allen County

MITA of Black ford Countyseope of out-of-network coverage, the Departments are interested
Moe le Boone counin finding out whether plans currently provide out-of-network

ol Ss oul ry
MHA of Clark Countycoverage for mental health and substance use disorder benefits. If
Moe ot chy CounSso, how is such coverage the same as or different than out-of-
MHA of Daviess Coumynetwork coverage provided for medical and surgical benefits?
MHA of Decatur County
MBA of DeKalb County, + . tae .
MHA ot Delaware County The regulations should require that plans provide information to consumers

MHA of Dubois Countyregarding the relative availability of in-network and out-of-network providers
MUA of Elkhart County,

MHA of Floyd CountylOt each of the medical specialties in order to evaluate the adequacy of the
MHA of Franklin Countyetworks and their equivalence

MHA of Fulton County

MHA of Gibson County

MHA of Greater Indianapolis

MHA of Greene County

MHA of Hamilton Count . . ~

MHA of Hancock Come. Cost Exemptions: Which aspects of the exemption for

MHA of Hendricks Countyincreased cost resulting from the parity requirement, if any,

Mun Mi een, ot require additional guidance? Would model notices be helpful to

MHA of Jackson € ountyfacilitate disclosure to Federal agencies, State agencies, and
if 0. ay ounty, se . . a .

MHA of Jeffercon Countyparticipants and beneficiaries regarding a plan's or issuer's
MHA of Johnson Countye] i i ion?

Nila of Kren Count ection to implement the cost exemption?

MILA of Kosciusko County

MIA of Lake County MHPAEA provides that plans may be exempt from the law if they can show
MILA of [xPorte coun that the parity requirements result in an increase in total costs of coverage by
MHA of Marshall County Over 2 percent in the first year and one percent for each subsequent year.
MHA of Monroe County
Mine of Morgan county The regulations should clarify that assessment of whether a plan qualifies
MHA of Perry County fora cost exemption must be determined on a retrospective basis and based
MHA of Porter County 7 jen ith i inste¢ . i
MHA of Putnam County on real experience with increased cost instead of hypothetical casts.
MHA of Randolph County
MHA of Rush County 7, Other issues: The agencies have also stated that they will
MHA of St Joseph County :
MIA of Spencer County cept comments on any other issues relevant to the
MHA of Steuben County ¢, i
MHA of Tippacanoe County evelopment of the MHPAEA regulations.
MBA of Union County
MHA of Vanderburgh County The regulations should provide a methodology for comparing types of

ae ‘ service across medical specialty areas to determine their equivalence. In
Mila of Watesh County dical special to det heir equivalence. I
MHA of Warrick County addition, the regulations could outline broad categories of care within which
MIIA of Wayne County parity will be required; for example, inpatient in-network services as a

MBA of Wells County category and inpatient out-of-network as a separate category.

www.mentalhealthamericaindiana.net

17.638.3501 + |.800.SSS.MHAT + F.317 638.3540.



Stephen C. McCaffrey, JD
President
Chief Executive Officer

MHA in Allen County
MHA of Blackford County
MHA of Boone County
MHA of Cass County
MHA of Clark County
MHA of Clay Counly
MHA of Clinton County
MHA of Daviess County
MHA of Decatur County
MHA of DeKalb County
MHA of Delaware County
MHA of DuBois County
MILA of Likhart County
MIA of Floyd County
MIA of Franklin County
MHA of Fulton County
MHA of Gihson County
MHA of Cireater Indianapohs
MHA of Groene County
MHA of Hamilton County
MHA of Hancock County
MHA of Hendricks County
MHA of Heary County
MHA of Howard County
MHA of Jackson County
MHA of Jay County
MHA of Jefferson County
MHA of Johnson County
MHA of Knox County
MHA of Kosciusko County
MHA of Lake County
MHA of LaPorte County
MHA of Lawrence County
MHA of Marshall County
MUA of Monroe County
MIA of Morgan County
MIIA of Parke County
MHA of Perry County
MHA of Porter County
MHA of Putnam County
MHA of Randolph County
MHA of Rush County
MHA of St Joseph County
MHA of Spencer County
MHA of Steuben County
MHA of Tippecanoe County
MHA of Union County
MHA of Vanderburgh County
MHA of Vigo. County
MITA of Wahash County
MHA of Warrick County
MHA of Wayne County
MHA of Wells County
MITA of White County

4

pS OE
ly America

May 26, 2009

Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration, Room N-5053
U.S Department of Labor

200 Constitution

Washington, DC 20210

Attention: MHPAEA Comments
To Whom It May Concern:

Mental Health America of Indiana (MHAI) 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.

Tn enacting the MHPAFA, 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.[1!] In order to achieve this goal the
implementing regulations must reilect 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 Jollowing enactment
of the Mentai Health Parity Act of 1996 when the vast majority of
employers substituted new restrictions on access to mental health benetits,
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 impese other types of financial requirements or
treatment limitations on benefits?

www.mentalheaithamericaindiana.net

1431 North Delaware Street + Indianapolis, IN 46202 + 317 638 3501] + 1.800.555 MHAL » F:317 638.3540



Stephen C. McCaffrey, JD
President
Chief Executive Offirer

MILA in Allen County
MITA of Blackford County
MHA of Boone County
MHA of Cass County
MHA of Clark County
MHA of Clay County
MHA of Clinton County
MHA of Daviess County
MHA of Decatur County
MHA of DeKalb County
MHA of Delaware County
MHA of DuBois County
MIIA of Elkhart County
MHA of Floyd County
MHA of Franklin County
MHA of Fulton County
MHA of Gibson County
MHA of Greater {ndianapolis
MHA of Greene County
MHA of Hamilton County
MHA of Hancock County
MHA of Hendricks County
MHA of Henry County
MHA of Howard County
MHA of Jackson County
MHA of Jay County
MHA of Jefferson County
MHA of Johnson County
MHA of Knox County
MHA of Kosciusko County
MHA of Take County
MHA of LaPorte County
MHA of Lawrence County
MHA of Marshall County
MIA of Monroe County
MHA of Morgan County
MUA of Parke County
MILA of Perry County
MILA of Porter County
MITA of Putnam County
MHA of Randolph County
MHA otf Rush County
MBA of St Joseph County
MBA of Spencer County
MHA of Steuben County
MHA of lippecanoe County
MHA of Union Coumy
MHA of Vanderbursh County
MHA of Vigo County
MIIA of Wabash County
MHA of Warrick County
MHA of Wayne County
MHA of Wells County
MILA of While County

’ Indianapolis, IN 46202 = 317.638.3501 + 1.800 554.MIIAI +» F:317.638.3540

M|+tAczd

Mental i }.2i. America

LF pete nn

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.”[4]

[I] HLR. REP. NO. 110-374, pt. 1 (2007) (Educ. & Labor Comm).

[2] Cunningham, P.J., Beyond Parity: Primary Care Physicians’
Perspectives on Access to Mental Health Care, Health Affairs, April 2009.
[3] Cite Sara Rosenbaum report on “Medical Necessity in Private Health
Plans”

[4] HLR. REP. NO. 110-374, pt. 2, Ways and Means Comm., 2007.

www. mentalhealthamericaindiana.net



M |. fA.

Mental : 1, America

Stephen C. McCaffrey, JD
President
Chief Executive Officer

The MHPAEA defines the term "financial requirement" as including
MHA in Allen County deductibles, co-payments, coinsurance, and out-of-pocket expenses. The

wae ofB Hackford County statute likewise defines the term "treatment limitation” as cluding limits
MHA of Cass County On the frequency of treatment, number of visits, or days of coverage "or
MHA of Clark County other similar limits on the scope or duration of treatment."

MHA of Clay County

MHA of Clinton County . woe . . .

MHA of Daviess County But the lists of types of limitations and requirements included in these
MHA of Decatur County definitions should not be interpreted as the only treatment limitations and

MUA of DeKalb Counly . . . * .
MILA of Delaware County financial requirements to which parity applies under the new law. Other

MISA of DuBois County examples of treatment limitations that plans disproportionately use to limit

wna of ie Comb, the "scope or duration of treatment" for mental! health or substance use
MHA of Franklin County conditions include the following:

MHA of Fulton County

MHA of Gibson Count . - ae 7 . .
MHA of Greater Indianapolis © Prior authorization that are applied more frequently and with higher

MHA of Greene County standards for approval;
MHA of Hamilton County + te . Seer . ae priterin:
MIIA of Hancock County More restrictive medical necessity and appropriateness criteria;
MIiA of Hendricks County « "Fail first" policies that require consumers to sutfer adverse
MILA of Henry County outcomes from a preferred treatment or medication before the
MITA of Howard County . Sais : 7
MITA of Jackson County treatment or medication recommended by their providers will be
MIIA of Jay County covered;

f Jeffers x i . .
MA ‘of Johneon cane © Step therapy requirements that force consumers to try a series of
MHA of Knox County preferred medications
Mate of Kosciusko a e Exclusion of certain specialized services like collaborative care,
MHA of LaPorte County assertive communily treatment, residential treatment, and partial
MHA of Lawrence County hospitalization;

MHA of Marshall County

MHA of Monroe County e Higher evidence-based standards; :

MHA of Morgan County » More frequent restrictions on treatments due to experimental status;

MHA of’ Parke County Stricter cost effectiveness requirements:

MHA of Perry County if ~ qui ”

MHA of Porter County e Lower provider lees;

MHA of Putnam County imitati 7 4 at ‘ Ss:

MITA of Randolph County . Limitations on covering specific types of providers;

MHA of Rush County © More restrictive provider licensure requirements;

Mus oft Joseph County © More limited preferred provider networks or phantom networks with
Spencet . . . -

MHA of Steuben County invalid phone numbers and names of providers no longer practicing

MHA of Tippecanoe County or accepting new patients;

vu olvandatehGnt © Requirement to prove current threat of harm to self or others as the

MHA of Vigo County justification for inpatient care; and

MHA of Wabash County . ae we
MIIA of Warrick County © Separate deductibles or lifetime limits.

MHA of Wayne County . .
MHA of Wells County The MHPAEA regulations should clarify that the parity standard applies to

MHA of White County 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.

www.mentalhealthamericaindiana.net

17.638.3501 + 1.800.555.MHAL + F:317.638.3540__

1431 North Delaware Street « Indianapolis, IN 46202


Stephen C. McCaffrey, JD
President
Chief Executive Officer

MHA in Allen County
MHA of Blackford County
MHA of Boone County
MHA of Cass County
MHA of Clark County
MHA of Clay County
MHA of Clinton County
MHA of Daviess County
MHA of Decatur County
MHA of DeKalb County
MHA of Delaware County
MILA of DuBois County
MHA of Elkhart County
MHA of Floyd County
MBA of Franklin County
MHA of Fulton County
MHA of Gibson County
MHA of Greate Indianapolis
MBA of’ Greene County
MHA of Hamilton County
MHA of Llancock County
MHA of Uendricks County
MIIA of Henry County
MLIA of Howard County
MIA of Jackson County
MIA of Jay County
MHA of Jefferson County
MITA of Johnson County
MHA of Knox County
MBA of Kosciusko County
MHA of Lake County
MHA of LaPorte County
MHA of Lawrence County
MHA of Marshall County
MHA of Monroe County
MHA of Morgan County
MHA of Parke County
MHA of Perry Connty
MHA of Porter County
MHA of Putnam County
MHA of Randolph County
MHA of Rush County
MHA of St Joseph County
MHA of Spencer County
MHA of Steuben County
MHA of Tippecanoe County
MHA of Union County
MHA of Vanderburgh County
MHA of Vigo County
MHA of Wabash County
MHA of Warrick County
MHA of Wayne County
MHA of Wells County
MHA of White County

4

» America

thacma

How do plans currently apply financial requirements or treatment
limitations to (1) medical or surgical benefits and (2) mental health and
substance use disorder benefits? Are these requirements or limitations
applied differently to both classes of benefits? De plans currently vary
coverage levels within each class of benefits?

Health plans often impose higher copays, deductibles, and other cost-sharing
requirements as well as reslricting the number of outpatient visits and
inpatient days covered. But these benefit design limitations are only the
most obvious examples of discriminatory treatment of mental health and
substance use care.

Regulations implementing the MHPAEA must take into account evidence
indicating mental health and substance use benefits have thus far been much
more strictly managed than medical and surgical benefit. States with
preexisting parity laws have not seen large increases in mental health and
substance use care utilization, presumably due to strict medical
management. A recent study reported that about two-thirds of primary care
physicians could not get outpatient mental health services for their patients a
rate that was at least twice as high as that lor other services due in part to
health plan barriers and inadequate coverage.[2]

Thus, it is critical that the regulations make clear that utilization
management techniques qualify as treatment limitations and as such may not
be applied to mental health and substance use benefits in a discriminatory
and more restrictive fashion.

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.

www. mentalheaithamericaindiana.net

1431 Nocth Delaware Street + Indianapolis, IN 46202 + 317,638. 3501 . 1,800. 555 MEIAI + F:317.638.3540.