May 28, 2009

Centers for Medicare and Medicaid Services

Department of Health and Human Services

7500 Security Boulevard 

Baltimore, MD 21244

ATTN: MHPAEA COMMENTS

Dear Sirs/Madams:

On behalf of the American Medical Student Association, which 

represents over 67,000 physicians-in-training, I thank you for 

allowing us the opportunity to submit our comments on 

implementing the Domenici-Wellstone Mental Health and 

Addiction Equality Act of 2008. As longtime supporters of parity 

legislation, we are pleased with its passage, which we consider 

an important step toward the goal of providing a!ordable, highquality health care in the United States. We also recognize that 

close attention must be paid to its implementation in order to 

preserve the intent of the Act: to facilitate the financing and 

delivery of individualized, patient-centered mental health and 

substance abuse services.

In theory, the reason parity has been found not to significantly 

increase total cost is that less intensive treatment options, used 

early, reduce the need for costly hospitalizations. More generally 

speaking, this is the rationale behind the concept of managed 

care. However, care must be taken that insurers apply best 

practices for e"cient delivery of health care, rather than more 

damaging cost-reduction measures that impose additional 

barriers to obtaining care. Furthermore, we believe that best 

practices, as disseminated by federal agencies, should be 

weighted toward patient-centered criteria such as e"cacy and 

patient satisfaction, rather than toward purely financial 

considerations. We favor regulations that ensure access to a wide 

range of evidence-based treatment options, and would like to 

present several issues that may a!ect access to care. 

One of our primary concerns is the way the term “treatment 

limitations” will be construed. It is our position that plans 

currently impose treatment limitations not explicitly mentioned 

in your solicitation of comments, and we fear that discriminatory 

application of such limitations as a response to parity legislation 

may undo the progress that parity represents.

In particular, administrative burdens on providers represent a 

significant barrier to treatment. Here, the experience of Federal 

Employees’ Health Benefit (FEHB) plans in Washington, D.C. is 

instructive. Although President Clinton’s Executive Order 

mandating parity for federal employees was successful in 

reducing deductibles and co-payments, the reaction of managed 

care companies administering the benefit plans hurt the same 

people that the order was intended to help. Within the first year, 

American Medical Student 

Association/Foundation

Quality, Affordable Healthcare for All

 Global Health Equity

 Enriching Medicine through Diversity

 Professional Integrity, Development, and 

Student Well-Being

1902 Association Drive

Reston, VA 20191 – 1502

 Phone: (703) 620-6600

 Fax: (703) 620-5873

 Web: www.amsa.org
many local providers left FEHB plan networks. Psychiatrists 

surveyed by the Washington Psychiatric Society in 2001 cited 

increased pre-authorization requirements and more frequent 

and time-consuming utilization reviews as reasons for leaving 

the plans, along with insu"cient reimbursement. The increase in 

administrative requirements may have been in anticipation of 

greatly increased numbers of claims. Four years later, only a 

small minority of psychiatrists, social workers, and clinical 

psychologists in the D.C. area were in FEHB networks and 

accepting new patients. Accordingly, a new patient might expect 

to have some di"culty obtaining in-network treatment. Also, 

passing the insurance paperwork itself on to patients is 

becoming an increasingly common practice among mental health 

care providers; this also increases the di"culty of obtaining care.

Therefore, we support a broad construction of the term 

“treatment limitations,” covering pre-authorization requirements 

as well as limits on frequency of treatment, days of coverage, 

and similar. In addition to imposing extra administrative burdens 

on providers and patients with the detrimental e!ects we have 

already noted, pre-authorization e!ectively limits the flexibility 

of treatment, particularly in mental health crisis situations. 

Regulation should ensure that it is not used in a discriminatory 

manner. 

Our second concern is the range of services to be covered at 

parity. Because mental healthcare spans a wide range of 

treatment and enabling services, parity should apply to coverage 

of a wide range of evidence-based treatment options, including 

those not traditionally covered by private insurance. The 

definitions of mental health benefits and substance use disorder 

benefits should be clarified such that they include all treatment 

modalities strongly supported by scientific evidence. It may be 

useful to refer to the American Psychological Association’s listing 

of empirically validated treatments for guidance. Mental health 

services that have no analogous medical/surgical services, such 

as residential treatment or partial hospitalization, may require 

specific regulation; certainly the percentage of cost borne by the 

patient should not exceed that for medical/surgical services of 

similar cost. In addition, we encourage the Departments to study 

the costs and benefits of reimbursement at parity for enabling 

services, which might allow greater access to mental health as 

well as medical/surgical services.

Finally, we are concerned with discriminatory use of utilization 

management. The clause of the Act mandating availability of 

plan information is a major step forward. While medical 

necessity criteria for many plans are already available to the 

public, evidence suggests that medically unjustified denials of 

claims occur on a regular basis. Multiple studies have suggested 

that utilization management “democratizes” mental health 

services to detrimental e!ect by limiting utilization based on 

diagnosis while failing to consider severity of illness. This 

amounts to denial of needed care. It fails to provide adequate 
care to the most severely ill patients, and takes treatment 

decisions out of the hands of the clinicians best able to make 

them.

The next logical step, then, is to establish, along with other 

quality assurance programs, a process for resolving parityrelated disputes by which patients and healthcare providers can 

challenge insurance decisions. Certain categories of disputes are 

easily foreseeable, such as those concerning whether a treatment 

modality is covered by the parity law, or those concerning 

whether a type of treatment limit is discriminatory with respect 

to analogous medical/surgical limits. The system must be able 

to examine decisions on a case-by-case basis in order to ensure 

appropriate care. Already a number of states mandate 

availability of third-party review of denied claims. These may 

provide guidance on implementing a fair and cost-e!ective 

process for procedural justice.

In summary, we urge you to: define “treatment limitations” 

broadly, to include pre-authorization requirements and other 

administrative burdens on providers and patients as well as 

frequency of treatment, days of coverage, and similar 

parameters; protect parity coverage of a broad range of 

evidence-based treatments for mental health and substance use 

disorders, whether traditionally covered or not; ensure that 

utilization management is used in a fair and non-discriminatory 

manner and in a way that does not endanger the most severely ill 

individuals; establish a process by which patients, healthcare 

providers, and other stakeholders may challenge parity-related 

insurance decisions.

Again, as future physicians, we appreciate the opportunity 

to o!er our opinion on implementing the MHPAEA and will 

be pleased to discuss any of our concerns in further detail. 

We hope that our comments may be of assistance in 

crafting fair and e!ective rules that increase the public’s 

access to mental health and substance abuse treatment.

Sincerely,

Ms. Farheen A. Qurashi

Jack Rutledge Legislative Director
Cc: Internal Revenue Service, Department of the Treasury 

Employee Benefits Security Administration, Department of 

Labor

 Hausman, K. (2001). Federal Parity Mandate Disappoints D.C. Psychiatrists. 

Psychiatric News, 36(13), 10.

 Health Affairs (2007). Press Release: Parity Legislation Could Actually 

Reduce Access. . . Retrieved 5/15/2009 from http://

www.healthaffairs.org/press/novdec0709.htm

 APA Society of Clinical Psychologists (n.d.). Empirically Supported Treatment 

Documents. Retrieved 5/24/2009 from http://www.div12.org/estpublications

 Mechanic, D. and McAlpine, D.D. (1999). Mission Unfulfilled: Potholes on 

the Road to Mental Health Parity. Health Affairs, 18(5), 7-21.