236 MASSACHUSETTS AVENUE, NE, SUITE 505, WASHINGTON, D.C. 20002 

May 3, 2010 

Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Re: RIN 1210–AB30, MHPAEA Comments 

Dear Sir or Madam: 

We appreciate the opportunity to submit comments to the Departments of Labor, Health and Human 

Services, and the Treasury on the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (MHPAEA) Interim Final Rule (IFR). 

State Associations of Addiction Services (SAAS) is the leading national organization that advocates 

on behalf of state associations of addiction prevention, treatment, and recovery providers, representing 

thousands of providers in 42 states around the country. The mission of SAAS is to ensure the 

availability and accessibility of quality drug and alcohol treatment, prevention, education, and 

research. Legal Action Center is a non-profit law and policy organization that works to expand 

treatment and prevention services for people with alcohol and/or drug addictions, people living with 

HIV/AIDS, and people with criminal records. 

Below is our response to the MHPAEA Interim Final Rule. Based on our analysis, we conclude that: 

1. The Interim Final Rule is fully consistent with the MHPAEA and will ensure that the new law 

is correctly implemented. 

2. Additional guidance to state policy-makers is needed to ensure that the MHPAEA is most 

effectively implemented. 

3. The Interim Final Rule correctly identifies quantitative and non-quantitative treatment 

limitations and other practices that restrict access to care as subject to the requirements of the 

MHPAEA. 

4. Guidance should swiftly be issued to affirm that the Interim Final Rule applies to Medicaid 

managed care plans. 

5. In providing guidance on a scope of services for substance use disorders, the Departments 

should utilize the substance use disorder treatment field’s existing body of evidence-based 

practices and standards of care. 

1. The Interim Final Rule is fully consistent with the Wellstone/Domenici Act and will ensure 

that the new law is correctly implemented. 

We were extremely pleased with the passage of the Wellstone/Domenici Act, and with it the promise 

of the elimination of barriers that have kept thousands of individuals with substance use disorders and 
mental illnesses from receiving critically important treatment services. Thank you for your work to 

develop the Interim Final Rule on the MHPAEA. The Interim Final Rule is entirely consistent with the 

MHPAEA statute and Congress’s goals of eliminating discrimination in group health plan coverage of 

mental health and substance use disorder and mental health treatment benefits and improving access to 

care. The Interim Final Rule will help to ensure that the MHPAEA is implemented correctly and as 

Congress intended, and will ensure that the promise of the MHPAEA, to close the unacceptably large 

treatment services gap, will be realized. 

2. Additional guidance to state policy-makers is needed to ensure that the MHPAEA is most 

effectively implemented. 

Our work with providers of addiction treatment services, people in recovery and their allies around the 

country has made it clear that additional guidance is needed as the MHPAEA is implemented. 

Specifically, guidance by the Departments is needed to ensure that state policy-makers best inform 

consumers and the broader public about the requirements of the MHPAEA. 

State insurance commissioners need continued guidance from the Departments to ensure greatest 

compliance with the MHPAEA. In particular, although the IFR preamble affirms that the MHPAEA 

does not preempt any State laws except those that would prevent the application of the MHPAEA, 

additional education and outreach is needed to ensure that managed care organizations continue to 

comply with State laws that provide greater protections or are more favorable from the standpoint of 

the insured or enrollee than the MHPAEA. 

In addition, guidance is needed on the MHPAEA provision allowing non-federal employer group 

health plans sponsored by State and local governments to opt out of the MHPAEA. Regulatory 

guidance should be given on the process non-federal government employers should follow in 

determining whether they choose to comply with the MHPAEA. Specifically, we urge the 

Departments to require that there be: 

 A certain period of time during which these plans must deliberate whether to opt out of the 

requirements of the MHPAEA 

 A transparent process where plan beneficiaries are notified of the possibility of the plan opting 

out of the MHPAEA 

 A process, for those government-sponsors plans that have opted out, to require that plans 

reexamine whether to comply with the MHPAEA after a certain amount of time; guidance 

should also be given to inform plans that have opted out that they can later decide to comply 

with the MHPAEA 

3. The Interim Final Rule correctly identifies quantitative and non-quantitative treatment 

limitations and other practices that restrict access to care as subject to the requirements of the 

MHPAEA. 

Inclusion of Quantitative and Non-Quantitative Treatment Limitations:

The Interim Final Rule’s inclusion of both quantitative and non-quantitative treatment limitations in 

the MHPAEA parity analysis is fully within the scope of the MHPAEA and is consistent with the 

statute and its legislative history. 
Medical management tools, identified in the Interim Final Rule as non-quantitative treatment 

limitations (NQTLs), are a fundamental means through which plans limit treatment. NQTLs were 

determined by both Congress and the Departments as a form of treatment limitation as defined under 

the law and hence subject to the purview of the statute and regulations. 

Limiting the scope of the MHPAEA analysis solely to day or visit limits or frequency of treatment 

limits would not achieve the legislation’s intended result of ensuring that substance use disorders and 

mental health benefits are not provided in a more restrictive way than benefits for other medical and 

surgical procedures. Excluding a major category of plan practices that significantly limit treatment 

from the MHPAEA analysis would be contrary to the letter and spirit of the MHPAEA. 

Identification of Additional Practices that Limit Consumer Access to Care:

The Interim Final Rule correctly recognizes that excluding certain types of providers from plan 

networks can significantly limit treatment and that plan practices to restrict network access, including 

setting low reimbursement rates, constitute non-quantitative treatment limitations that must be subject 

to the MHPAEA analysis. 

In addition, the Interim Final Rule recognizes that high out-of-pocket spending requirements deter 

individuals from accessing substance use disorder and mental health services. As a result, the Interim 

Final Rule correctly recognized that individuals need a combined mental health/substance use disorder 

and medical deductible to keep out-of-pocket spending requirements at a reasonable level. 

4. Guidance should swiftly be issued to affirm that the Interim Final Rule applies to Medicaid 

managed care plans. 

The Centers for Medicare and Medicaid Services (CMS) should quickly issue guidance clarifying that 

the Interim Final Rule applies to Medicaid managed care plans because there is no rationale for a 

separate, different parity standard for Medicaid managed care plans. 

The MHPAEA statute and its legislative history do not include any distinction between how the law 

applies to group health plans and Medicaid managed care plans. The Interim Final Rule implements 

the MHPAEA, and Medicaid managed plans must adhere to the MHPAEA. Therefore they must 

comply with the Interim Final Rule. 

Until CMS affirms that the Interim Final Rule applies to Medicaid managed care plans, there will 

likely be significant confusion as the MHPAEA is implemented for Medicaid managed care plans. 

The MHPAEA is in effect, and guidance is quickly needed to ensure the Medicaid managed care plans 

comply with the requirements of the current law. 

5. In providing guidance on a scope of services for substance use disorders, the Departments 

should utilize the substance use disorder treatment field’s existing body of evidence-based 

practices and standards of care. 

The Interim Final Rule includes a number of references to “generally recognized independent 

standards of current medical practice” and the need for managed care organizations to use these 

standards in making decisions about coverage for mental health and substance use disorders.

The substance use disorder treatment field has a body of widely accepted standards of care and 

evidence-based practices for the treatment of substance use disorders. In providing additional guidance 
to plans on standards of care and the scope of services covered in substance use disorder treatment 

benefits, the Departments should adopt these recognized best practices and standards so that plan 

decisions best reflect recognized clinically appropriate standards of care for substance use disorder 

treatment. In providing this guidance, the Departments should reflect the MHPAEA by ensuring that 

more favorable State laws are preserved. 

Specifically, the Departments should:

 Adopt standards developed by experts in the substance use disorder treatment field including 

the National Quality Forum’s “National Standards for the Treatment Of Substance Use 

Conditions” 

 Explicitly identify these standards and criteria as “generally recognized independent standards 

of current medical practice,” in addition to the Diagnostic and Statistical Manual of Mental 

Disorders, the International Classification of Diseases, and State guidelines, which group health 

plans must use to define the services covered in SUD benefit packages. 

Should the Departments define a scope of services constituting substance use disorder treatment, they 

should include but not be limited to, the levels of care identified by the American Society of Addiction 

Medicine (Early Intervention; Outpatient Treatment; Intensive Outpatient/Partial Hospitalization; 

Residential/Inpatient Treatment; and Medically-Managed Intensive Inpatient Treatment). Including 

this full continuum will better ensure that people with substance use disorders receive the appropriate 

clinically determined type and level of care. 

Thank you for the opportunity to submit comments on the MHPAEA Interim Final Rule. Please feel 

free to contact us if you have any questions or need additional information. Thank you for your 

careful consideration. 

Sincerely, 

 Becky D. Vaughn Gabrielle de la Guéronnière, JD 

CEO Director for National Policy 

State Associations of Addiction Services (SAAS) Legal Action Center