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 Avenue, NW 

Washington, DC 20210 

Attention: MHPAEA Comments 

 

Re: Mental Health Parity and Addiction Act of 2008 (MHPAEA) 

To Whom It May Concern: 

The New Jersey Association of Mental Health Agencies (NJAMHA) is grateful for the 

opportunity to submit comments for your consideration in advance of the issuance of 

rules and regulations related to the Mental Health Parity and Addiction Equity Act of 

2008 (MHPAEA). 

 

NJAMHA is a statewide association of 125 nonprofit community behavioral health 

providers. Annually, these organizations collectively serve an estimated 400,000 adults 

and children with serious mental illnesses and serious behavioral disorders. 

NJAMHA has long advocated for the passage of federal legislation that would assure 

parity between physical and mental health coverage for plans that cover both. NJAMHA 

is optimistic that the MHPAEA will address the dire economic and social consequences 

of untreated mental illness. 

An estimated 25 percent of Americans –one in four adults – suffer from a diagnosable 

mental illness in any given year, or close to 60 million adults on a nationwide basis. 

Untreated mental illness significantly reduces productivity in the workforce and 

materially drives up health care costs. 

Studies have shown that recovery from mental illness is possible with treatment and 

support. However, for far too many people with limited mental health plan coverage, the 

costs associated with treatment, including medications, is cost prohibitive. NJAMHA is 
optimistic that with expanded insurance coverage for mental illness, more people will 

seek treatment, and more providers will be able to render the care needed. 

Following are NJAMHA’s comments on the priority areas requested: 

• Types of treatment limits plans currently impose 

Panel of Providers and Accessibility: Often plans limit the panel of behavioral 

health providers and maintain unacceptable geo-access criteria presenting barriers 

to service, especially among persons who reside in remote or rural localities. In 

reality, treatment is not sought solely due to these limitations. 

Limits on Service Array: The full continuum of behavioral health services is 

often not offered by plans, regardless of medical necessity, as compared to the 

wide array of physical health services that are covered, as dictated by medical 

practice guidelines. The eventual regulations must prohibit artificial limitations 

on the scope of services medically indicated for symptom reduction and recovery. 

Utilization Management: Parity in states has sometimes increased the application 

of utilization management techniques to restrict behavioral health care, especially 

with reference to effective antipsychotic medications, which tend to have a higher 

cost. Also, plans tend to step up the use of prior authorization processes when 

parity laws are established in states. Federal regulations must safeguard against 

the overuse and inappropriate application of utilization management tools. And 

for states that control for excessive utilization management, there must be no 

exemptions of state laws for those that provide a higher level of consumer 

safeguards. 

Fail-First Policies: In contrast with physical health policies, plans tend to choose 

to adopt fail-first policies. This means that behavioral health treatment options 

known to have been effective for particular consumers, will be unavailable until 

less costly methods have been employed. This certainly would not be tolerated 

for patients undergoing cancer treatments, for example. 

• Terms in the statute that require additional clarification to facilitate compliance 

Pre-Existing Conditions: This is a conundrum, which continues to frustrate 

practitioners and consumers, will require federal guidance. In that behavioral 

health issues often begin at an early age, discordant policies between physical 

health and behavioral health tend to be all too obvious and in dire need of 

correction. 

• Current disclosure practices by plans regarding medical necessity determinations

and denials of mental health benefits. 

Mystery of Medical Criteria: Medical necessity criteria for behavioral health are 

often cloaked. Families and consumers are not routinely advised of medical 

necessity criteria and are all too frequently denied on the basis of requirements 

that frequently change and are not routinely shared on a routine basis. Most 
commonly, consumers become aware of the criteria through an Explanation of 

Benefits (EOB) that informs of a denied claim. There does not seem to be a 

consistent standard by which medical necessity criteria, that all too frequently do 

not comport with best practices, is promulgated, particularly with respect to 

behavioral health. Frequently behavioral health benefits are separated out from 

physical health and administered by another entity, which creates additional 

confusion and access hurdles. 

Medical Necessity: The term “clinical necessity” better describes the basis of 

authorization for behavioral health services due to the different models of mental 

health interventions, including rehabilitative support services. 

Denials: Expedited reviews of the request for psychiatric emergency services, or 

for critical psychiatric medications, by practitioner certification, should be of 

highest order. The parity regulations and guidelines must so indicate. For 

persons with behavioral health issues, the denial of access to services may be 

catastrophic. This is equivalent to physical health care where an emergency 

situation is defined as life threatening. 

Notification of Denial Decisions and Appeal Processes: For behavioral health 

consumers, it is absolutely necessary to assure that plan policies and procedures 

include capturing information about consumers’ representatives. This is routinely 

done through health advance directives. Twenty-five states now have Psychiatric 

Advance Directives laws, and this number is growing through the Wellness and 

Recovery movement across the country. The appointed representative, especially 

in times of crisis and destabilization, must be aware of plan decisions and appeal 

processes. 

NJAMHA looks forward to the delineation of rules and guidelines that protect 

consumers of behavioral health services and place their treatment benefits on par 

with traditionally more expansive physical health benefits. 

Once again, thank you for this opportunity to voice our suggestions and concerns 

to assure that the final rules and guidance best serve behavioral health 

practitioners and the consumers they serve. 

If you have any questions on these comments, please do not hesitate to contact me 

at (609) 838-5488, extension 292. 

Sincerely, 

Debra L. Wentz, Ph.D. 

CEO 

Cc: NJAMHA Board of Directors 

 NJAMHA Public Policy Committee 
•