May 3, 2010 

Hilda L. Solis 

Secretary 

Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Kathleen Sebelius 

Secretary 

Department of Health and Human Services 

200 Independence Avenue, SW 

Washington, DC 20201 

Timothy Geithner 

Secretary 

Department of the Treasury 

1500 Pennsylvania Avenue, NW 

Washington, DC 20220 

Re: Interim Final Rules Under the Paul Wellstone and Pete Domenici 

Mental Health Parity and Addiction Equity Act of 2008; Final Rule; Docket 

No. CMS-4140-IFC; [RIN 0938-AP65]; 75 Federal Register 5410 (February 

2, 2010). 

Dear Secretaries Solis, Sebelius, and Geithner: 

The American Psychiatric Association (APA), the national medical specialty 

society representing more than 37,000 psychiatric physicians, appreciates the 

opportunity to submit these comments on the Departments of Labor, Health and 

Human Services, and the Treasury (The Departments) interim final rule (IFR) on 

the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 (Sections 511 and 512 of PL 110-343, October 3, 2008) 

(MHPAEA).1

 APA has also joined with the Parity Implementation Coalition in 

filing comments on the IFR, but we are pleased to offer our specific comments 

here. 

It was estimated that enactment of MHPAEA would improve coverage for over 

113 million people, including 82 million individuals covered by employer 

 

1

 Pub. L. 110-343 
sponsored plans that were not subject to state regulations. The law will ensure that mental 

health coverage will now be treated the same as all other forms of healthcare coverage 

and we greatly appreciate that the Departments have issued these rules on an interim final 

basis to ease implementation of the law. APA was pleased to submit comments on the 

Departments’ request for information (RFI) which was issued on April 28, 2009, and to 

address the numerous areas of open interpretation in the statutory language. APA 

believes that issuing these rules on the interim basis is the best way to provide clear and 

consistent guidance to plans and issuers on how to structure their benefits to comply with 

MHPAEA and we look forward to working with the Departments in ensuring that 

compliance is met. 

Classification of Benefits and Scope of Services 

APA is extremely pleased that the Departments have taken the approach to classify 

benefits into specific categories and apply the requirements from MHPAEA across those 

categories. We believe that this is a logical system and will greatly simplify comparisons 

when determining if a plan or issuer has complied with the law. 

We agree with the Departments that the appropriate determining criteria for finding the 

predominant financial requirements and treatment limitations should be within a given 

classification of benefits. We believe that it is required under the statute that the 

regulations from MHPAEA apply both across and within these classifications. APA also 

agrees with the Departments that six classifications of benefits proposed in the rule2

 are 

clear and will cover the full scope of benefits provided in both mental health and 

medical/surgical care. The IFR also states that a plan must offer benefits for any mental 

health or substance use disorder covered in each classification for which they also offer 

medical surgical coverage. 

While the Departments do state that the definition of each classification may vary by 

plan, APA requests the Departments to clarify in the final rule or in any subsequent 

guidance that these classifications must cover all benefits provided by the plan. The 

Departments must clearly state that a plan may not exclude a particular service or benefit 

simply because it does not fall squarely into one of the six classifications proposed or 

because there is no analog on the medical/surgical side. There are frequently used mental 

health and substance use disorder (MH/SUD) services which do not fit neatly into one 

category or have a comparable medical/surgical service, but which nonetheless should be 

covered under MHPAEA. Additionally, APA would appreciate a clarification that 

insurers cannot create new benefit classifications for either mental health/substance use 

disorder treatment or medical/surgical care to skirt enforcement of the law as we have 

grave concerns that plans will create such classifications and shift definitions of certain 

benefits to avoid providing mental health and substance use disorder benefits at parity.3

 

 

2

 The six classifications as described in the rule are: inpatient, in-network; in-patient, out-of-network; 

outpatient, in-network; outpatient, out-of-network; emergency services and prescription drug benefits. 

3

 For a full discussion of the scope of comparable and non-comparable services and types of treatments, we 

refer the Departments to the comments submitted by the PIC on April 30, 2010. 
APA urges the Departments to revise this section for the final rule and make it clear that 

plans may not circumvent the law or the rules by claiming that a benefit or service falls 

outside of these six classifications and therefore does not have to be covered. 

Recommendations: APA supports the six benefit classification scheme as outlined 

by the Departments, however we urge the Departments to clarify that the universe 

of health benefits for these purposes is limited to these classifications. We also urge 

the Departments to clarify that these classifications address the issue of scope of 

services for this reason. 

Cumulative Financial Requirements and Quantitative Treatment Limitations 

APA generally agrees with the approach that the Departments have taken with regard to 

determining the “predominant limitation” applied to “substantially all” benefits in a plan. 

As we expressed in our comments to the RFI, APA believes that it would be consistent 

with prior policy to set limits in line with those set for the Mental Health Parity Act of 

1996 (MHPA). We also support the Departments’ policies regarding those benefits 

which are subject to “zero sum limits.” We agree that services which are not subject to a 

copayment, such as well baby visits or visits for allergy shots, should not be included in 

the calculations when determining the predominant limit. 

APA would like to express our strong support for the Departments’ clarification that 

cumulative financial requirements, such as deductibles and out-of-pocket maximums, 

must be structured as a single combined limit. We stated in our RFI comments that we 

fully supported this position and believe that it is far more consistent with the intent of 

MHPAEA. As stated in the statute, MHPAEA prohibits financial requirements including 

deductibles and out-of-pocket maximums which are more restrictive than applied to 

medical and surgical benefits and requires that there be no separate cost-sharing 

requirements applicable only with respect to mental health or substance use disorder 

treatment. APA believes that this language demonstrates the intent of Congress to 

discourage, if not outright prohibit, the application of separate cumulative financial 

requirements. 

APA believes that this position will greatly benefit patients who seek treatment for 

mental health and substance use disorder treatment. In particular, this protection would 

most directly benefit those with serious and persistent mental illness, many of whom have 

co-morbid medical and surgical conditions and would have difficulties meeting two 

separate deductibles. Frequently, patients first seek treatment from a primary care 

physician or similar provider for the physical symptoms of a mental illness (e.g. fatigue, 

loss of appetite, etc.) before being referred for mental health care. Sometimes the treating 

physician will notice that an existing patient is presenting with signs of a mental illness 

and subsequently refer him or her for mental health evaluation and treatment. In these 

instances, the patient has frequently already met the deductible and the imposition of a 

separate, and equally high, out-of-pocket expenditure may serve as a deterrent to seeking 

appropriate care. In this setting, as in so many others, “separate but equal” is inherently 

not equal. 
Some comments submitted to the Departments asserted that separate, but equal 

deductibles would actually be more beneficial to patients given the lower mental health 

deductibles provided by some plans. APA is unaware that such allegedly beneficial 

deductibles are standard practice. Further, there is nothing in MHPAEA that would 

prevent a plan from providing mental health and substance use disorder services at lower 

cost sharing of any kind, including setting a lower threshold within the deductible for 

MH/SUD services. Separate deductibles only serve as a barrier to accessing mental 

health treatment and would undermine the law. Therefore, APA strongly supports the 

interim final regulation as it requires plans to maintain single combined deductibles or 

out-of-pocket maximums for all benefits and urge the Departments to finalize this 

regulation. 

Recommendation: APA strongly supports the requirement that plans offer a single 

combined deductible for all health costs as we believe it follows the intent of 

MHPAEA and will greatly benefit patients. We urge the Departments to include 

this requirement in the final rule. 

Non-Quantitative Treatment Limitations 

APA strongly supports the Departments’ inclusion of non-quantitative treatment 

limitations (NQTLs) as impermissible restrictions under MHPAEA and we believe that 

this addresses the central intent of the statute. As we stated in our comments on the RFI, 

the most visible methods of controlling costs and perpetuating discrimination, such as 

visit limits and higher cost sharing, are not always the most insidious. NQTLs prevent 

patients from gaining access to adequate mental health and substance use disorder 

treatment, which is the very problem MHPAEA sought to rectify. 

APA believes that the statute includes the authority for the regulations to cover these 

NQTLs and that the Departments acted appropriately by including them in the rule. The 

section concerning the parity of treatment limitations in MHPAEA closely follows the 

language concerning financial requirements, with some key differences. The statute 

states that the definition of treatment limitations “includes limits on the frequency of 

treatment, number of visits, days of coverage, or other similar limits on the scope of 

duration and treatment.”4

 However, the language regarding financial requirements has 

examples yet no similar reference to “other similar limits.” We believe that these NQTLs 

are exactly the limits on scope and duration of treatment envisioned, yet not enumerated, 

by Congress in the statute. 

Since MHPAEA became effective, we have seen a number of confusing and often 

deceptive practices on the part of insurers which we believe are intended to circumvent 

the law. Prior to the issuance of the IFR, there was a wide variation in how the law was 

applied and in many instances, these changes actually prevented patients from accessing 

care. APA was informed by many of our members that insurers began imposing new 

 

4

 29 U.S.C. § 1185a(a)(3)(B)(iii). 
requirements for prior authorization and the submission of treatment plans for mental 

health services where there were no comparable requirements on the medical/surgical 

side. In other cases, we received examples of insurers dropping coverage for essential 

mental health services when there was ample coverage for similar benefits for 

medical/surgical care. While the stated reason for these requirements in most cases was 

benefit management, these policies went far beyond legitimate practice. Further, several 

insurers falsely stated that the imposition of these new requirements was in fact required

by MHPAEA. Whether these policies were designed to limit access to appropriate 

mental health care, drive health professionals out of the insurers’ networks, or simply to 

cut costs, APA firmly believes that these practices are a clear violation of MHPAEA as 

they limit patients’ access to care and perpetuate the very discriminatory practices that 

MHPAEA was enacted to eliminate. 

Upon receiving reports of this shift in the absence of federal guidance, APA moved 

swiftly to intervene to pressure insurers to reverse these changes and alerted the 

Departments to these attempts to undermine the law.5

 Given the clear reaction from the 

insurers to take advantage of any ambiguity in the statute and impose policies to 

undermine the effectiveness of the law, we are extremely pleased to see that the 

Departments addressed these practices in the regulations. 

The application of NQTLs such as restrictive formulary management, overzealous 

application of prior authorization and the discriminatory methods of calculating usual and 

customary rates are all limits on the scope and duration of treatment that a patient 

receives. For example, if an insurer requires prior authorization before any visit to a 

psychiatrist and also requires that the psychiatrist submits and has a treatment plan 

approved after every three visits when no such requirements are applied comparably to 

the medical/surgical side, it is reasonable to conclude that the main purpose of such 

requirements is to discourage treatment by making it unreasonably difficult for a 

psychiatrist to treat a patient. Similarly, if the insurer has set reimbursement rates for 

psychiatrists so unreasonably low that it effectively forces those physicians out of the 

network, their patients will be unable to maintain the continuity of the relationship which 

is essential to good care. This is a clear non-quantitative limit on the scope and duration 

of the treatment the patient receives and which is almost never imposed on the 

medical/surgical benefit. 

Additionally, many insurers use different provider network standards for MH/SUD 

coverage or use a different calculation to set UCR rates for mental health professionals. 

Not only do we believe that these practices are similarly prohibited NQTLs, we would 

like the Departments to clarify that these are two independent NQTLs and that meeting a 

network access standard does not relieve a plan from an obligation to use the same 

method of calculating reimbursement rates for MH/SUD services. APA is concerned that 

without a clear statement to this effect and examples demonstrating the issue, plans will 

inappropriately assume their duty to satisfy both will be discharged after complying with 

one in a superficial manner. However, this will result in the same access issues for 

patients as existed before the enactment of MHPAEA. 

 

5

 See APA’s letter to the Departments dated November 2, 2009, as attached to these comments. 
APA appreciates that the Departments addressed many of the issues raised in our 

comments on the RFI, in addition to those raised by many other groups, and that the 

regulations preserve the intent of the law to abolish discriminatory insurance practices so 

frequently applied to mental health and substance use disorder benefits. While many of 

the comments submitted on the RFI focused on current industry practices and how to 

maintain those management techniques, passage of MHPAEA was a clear statement that 

the status quo is no longer acceptable and these interim regulations support that 

statement. Therefore, we fully support the inclusion of NQTLs in the IFR and urge the 

Departments also add additional illustrations and examples of NQTLs including: 

• Prior authorization and concurrent review requirements for outpatient services, in 

and out-of-network; 

• Prior authorization and concurrent review requirements for inpatient services, in 

and out-of-network; 

• Reimbursement rate issues for in and out-of-network; 

• Formulary design; 

• Service coding; 

• Provider network criteria; 

• Policy coverage conditions and exclusions; and 

• Geographic limitations to state of issuer, in and out-of-network. 

We understand the difficulties that the Departments faced when deciding on an operative 

standard by which to judge whether the NQTLs were more restrictive in a MH/SUD 

benefit as compared to a medical surgical benefit. We concur with the Departments that 

the NQTL on the MH/SUD benefit should be comparable to the limit on the 

medical/surgical benefit and the limit on the MH/SUD benefit should not be applied more 

stringently than on the medical/surgical benefit. We believe that this standard follows the 

intent and the language of the MHPAEA statute. We do, however, have some concerns 

and request that the Department clarify several points in the final rule. 

APA fully agrees with the Departments that MHPAEA prohibits the imposition of 

NQTLs through “[...]any processes, strategies, evidentiary standards, or other factors 

used in applying the non-quantitative treatment limitation to mental health or substance 

use disorder benefits in the classification are comparable to, and are applied no more 

stringently than, the processes, strategies, evidentiary standards, or other factors used in 

applying the limitation with respect to medical/surgical benefits in the classification, 

except to the extent that recognized clinically appropriate standards of care may permit a 

difference.”6

 We believe that this is a reasonable standard. We also concur with the 

examples provided in which plans apply similar limitations in disparate methods or use 

counseling services as a gatekeeper on the MH/SUD side as violating the law. 

We have serious concerns that the exception noted in the IFR may inadvertently 

undermine the strength of the regulations. For example, the use of the term “recognized 

 

6

 75 Fed. Reg. at 5416. 
clinically appropriate standards of care” which may permit a difference in application 

may allow insurers to use proprietary standards of treatment which are lower than the 

norm. We request that in the final rule, the Departments clarify that any “recognized” 

standard of care for purposes of the NQTL exceptions process must be: (1) 

an independent standard that is not developed solely by a single health plan or plans; (2) 

based on input from multiple stakeholders and experts, such as academic researchers, 

senior practicing clinicians, and consumer and advocacy leaders with subject matter 

expertise in addition to a health plan or its advisory panels; (3) recognized or 

accepted by multiple nationally recognized physician and patient organizations and/or 

nationally recognized accrediting organizations that are responsible for developing 

quality standards; and (4) based on objective scientific evidence, such as peer-reviewed 

publications of control group research trials or expert consensus panels. We believe that 

there is ample evidence to support this practice give CMS’s reliance on similar input for 

Medicare national coverage determinations and through the work of the Medicare 

Coverage Advisory Committee (MEDCAC). This will prevent the application of 

arbitrary exclusions simply to circumvent the regulations as written and therefore we urge 

the Departments to clearly define “recognized clinically appropriate standards of care” in 

the final rule or any further guidance. 

While we agree with the “comparable” and “no more stringently applied” standard for 

NQTLs, we are concerned that there is not a clear statement that these limitations must 

also comport with the aforementioned “predominant” and “substantially all” test for all 

limitations under the law. The statutory test for all limitations applied to a MH/SUD 

benefit under the law is that they must not be more restrictive than the predominant 

limitation applied to substantially all the medical/surgical benefits. Therefore, it must be 

made clear that the NQTLs must also meet that requirement. It would be inappropriate if 

the regulations allowed certain NQTLs to be applied to MH and SUD treatment when 

they only apply to a fraction of the medical/surgical benefits. APA urges the 

Departments to clarify this section of the regulation in the final version of the rule. 

Recommendations: APA believes that regulation of NQTLs is a critically important 

issue under MHPAEA and that the law requires that they be regulated in the same 

manner as quantitative treatment limitations. Therefore, we recommend the 

Departments finalize the requirements imposed on NQTLs in this IFR and also 

clarify that they are subject to the same “predominant” and “substantially all” 

standards as QTLs. We also urge the Departments to add to the list of NQTLs 

which are covered under MHPAEA. 

Availability of Plan Information 

MHPAEA includes a requirement that plans must disclose the reason for any denial of 

reimbursement or payment for services with respect to MH/SUD benefits, if requested. 

However, patients have encountered significant delays in receiving the required 

disclosure when requested and APA requests that the Departments set forth a timetable 

for plans to provide such information. This is particularly important when the denial is 

based on medical necessity criteria since, absent any explanation from the plan, the 
patient has little to no information as to why payment was denied and cannot seek to 

remedy the situation. Most patients will try to appeal the decision and the summary plan 

information about medical necessity determinations is inadequate for this purpose. 

Therefore, it is essential that the provision of this information be timely. Specifically, 

APA urges the Departments to require that information regarding the plan’s medical 

necessity criteria be provided to the insured within three days of an adverse care decision 

Recommendation: APA urges the Departments to require that, in the event of a 

denial, plans provide patients information regarding medical necessity criteria 

within three days to facilitate patient appeals. 

Application to Medicaid Managed Care Plans 

APA has significant concerns that the Departments have omitted an essential part of the 

regulations under MHPAEA, namely the application of these regulations to Medicaid 

managed care plans. The statutory language of MHPAEA clearly applies to Medicaid 

plans and therefore Medicaid managed plans must comply with the law. The 

Departments, however, have exempted these plans from the regulations without a clear 

reason. Given the high percentage of Medicaid beneficiaries whose benefits are 

administered through a managed care program and the high number of Medicaid 

beneficiaries with mental illness, APA believes the lack of regulation in this area could 

be confusing at best and also potentially harmful to patients. We urge the Departments to 

move swiftly to issue regulations for this segment of the population and recommend that 

these regulations and guidance be consistent with those issued under MHPAEA. 

MHPAEA modified the Public Health Service Act (PHSA) to require that group health 

plans comply with the same policies as all other plans covered by the law and the 

Medicaid managed care statute refers to this section and mandates that managed care 

plans “comply” with its provisions. Specifically, the Social Security Act Section 

1932(b)(8) specifies that “[e]ach Medicaid managed care organization shall comply with 

the requirements of subpart 2 of Part A of title XXVII of the PHSA [42 U.S.C.A. 300gg5 et seq.] insofar as such requirements apply and are effective with respect to a health 

insurance issuer that offers group health insurance coverage.”7

 The statutory reference in 

the quote refers to the mental health parity provisions as passed in the Mental Health 

Parity Act (MHPA) of 1996 and as modified by MHPAEA. Thus, the Medicaid managed 

care statute requires that these plans comply with both the 1996 and the 2008 parity 

requirements. 

Given the clear application of the law to these types of plans and the potentially 

significant impact of the lack of guidance for these plans, it is imperative that the 

Departments offer regulatory guidance on this issue for Medicaid managed plans. APA 

also asks that this guidance be consistent with, if not the same, as the regulations and 

guidance issued for all other plans covered by MHPAEA to avoid any confusion in 

application. 

 

7

 42 U.S.C. § 1396u-2(b)(8) (2000). 
Recommendation: It is essential for the Departments to ensure comprehensive and 

uniform compliance with MHPAEA and therefore we urge the Departments to 

swiftly issue regulations for Medicaid managed care plans and that these regulations 

be substantially similar, if not the same as the IFR. 

Preemption and State Laws 

As APA noted in our comments to the Departments on the RFI, numerous states had 

already implemented their own mental health parity laws at the time that MHPAEA was 

enacted. While these laws vary greatly from state to state, many of them were a response 

to the weaknesses in MHPA of 1996 and contained parity protections similar to those in 

MHPAEA. As stated in our earlier comments, APA believes that state parity laws with 

stronger protections than those contained in the MHPAEA will not ordinarily be 

preempted by the Act and strongly supports the Departments’ statement in the IFR that 

confirms that interpretation. 

Recommendation: APA agrees with the Departments that MHPAEA should not 

supersede the application of stronger state laws on parity and urge the Departments 

to include this guidance in the final rules. 

Cost Exemption

MHPAEA permits an exception to the mental health parity requirements for plans that 

experience a cost increase of two percent in the first year of implementation of parity and 

one percent in subsequent years.8

 As APA indicated in our comments on the RFI, it is 

unlikely that many insurers will apply for the cost exemption since past experiences with 

parity implementation, at both a federal and state level, show that costs do not increase 

dramatically. However, we appreciate the Departments inviting comments in order to 

provide additional guidance in this area. 

The statutory language of MHPAEA is clear that this exemption must be based on actual 

costs incurred, as was the case with the implementation of the cost exemption provisions 

of MHPA of 1996. It would be a clear violation of the law to allow any cost projections 

or determinations of cost increases based on actuarial estimates. Therefore, the 

Departments should reject any argument to allow plans to use actuarial cost projections to 

establish an exception to MHPAEA. 

In implementing MHPA of 1996, the Departments similarly implemented an exception to 

parity requirements for plans whose costs increased one percent. The regulations 

discussed at length the method for calculating the cost increase. The 1996 regulations 

outline various options for making the calculation, including a purely retrospective 

approach where increased costs are based on actual experience, and a purely prospective 

approach where increased costs are based on actuarial projections. The Departments 

adopted a modified retrospective approach based on actual costs over a certain period of 

 

8

 29 U.S.C. § 1185a(c)(2)(A). 
time. The Departments believed that using the costs that the plans actually incurred was 

important to assure that exceptions were “based on actual experience under the MHPA’s 

parity requirements and not on projections or estimates of such experience.” In like 

manner here, the Departments should ensure that actual costs, and not actuarial 

projections are used to determine eligibility for the exemption. 

The 1996 regulations also set out a specific formula for calculating the one percent 

exception. The formula’s numerator and denominator both relied on a calculation of 

“incurred expenditures.”9

 As stated by the regulations, the term “incurred expenditures” 

means “actual claims incurred during the base period.”10 Once again, the Departments 

were clear that the exemption calculation must be based on actual costs. We request that 

the Department reject any argument to the contrary. 

Recommendations: APA recommends that the Departments clarify in the final rule 

that any application for the cost exemption must be retrospective and based on 

actual costs incurred, as opposed to projected or estimated costs. 

Thank you for your consideration of these comments on this interim final rule. We look 

forward to working with the Departments in the future to develop and implement any 

policy change. If you have any further questions, please contact Nicholas Meyers, 

Director, Department of Government Relations, at nmeyers@psych.org or Jennifer 

Tassler, Deputy Director, Regulatory Affairs, at jtassler@psych.org or at (703) 907-7800. 

Sincerely, 

James H. Scully Jr., M.D. 

Medical Director and C.E.O., American Psychiatric Association 

 

9

 62 Fed. Reg. 66955. 

10 Id. 
November 2, 2009 

The Honorable Hilda L. Solis 

Secretary of the Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

The Honorable Kathleen Sebelius 

Secretary of the Department of Health and Human Services 

200 Independence Avenue, SW 

Washington, DC 20201 

The Honorable Timothy Geithner 

Secretary of the Department of the Treasury 

1500 Pennsylvania Avenue, NW 

Washington, DC 20220 

Re: Implementation of the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act of 2008. 

Dear Secretaries Solis, Sebelius, and Geithner: 

I am writing to you on behalf of the American Psychiatric Association 

(APA), the medical specialty representing more than 38,000 psychiatric 

physicians nationwide, to alert the Departments of Labor, Health and Human 

Services, and Treasury to problems regarding the implementation of the Paul 

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 

Act of 2008 (MHPAEA) in the absence of federal regulations. I am also 

urging the Departments to issue guidance to insurers on how to properly 

comply with the law. 

We understand from letters recently sent from Secretary Sebelius to Senator 

Al Franken and Representative Patrick Kennedy that the regulations 

implementing the MHPAEA will be delayed until January of 2010. 

However, APA has become aware that many health plans are imposing new 

requirements on mental health professionals under the guise of benefit 

management which seek to undermine the intent of the law. For example, 

many plans are now requiring prior authorization and treatment plans for 

mental health treatment where there are no comparable requirements 

imposed on medical and surgical treatments. Not only is this 
in violation of the law against discriminatory treatment limitations, but also undermines 

the sufficiency of the network of mental health professionals as it drives providers out of 

health plan networks. APA believes that this practice is in blatant contradiction of the 

intent of the MHPAEA and is occurring due to the absence of federal guidance in this 

area. We are urging the Departments to take immediate action to stop this practice. 

Further, APA has heard that some plans are taking an inappropriately limited view of the 

scope of services covered under the MHPAEA definition of benefits. While the law states 

that “benefits” means “benefits with respect to services,” some plans are interpreting that 

to exclude coverage of essential treatment at all levels of care for mental illness and 

substance use disorder. We have spoken to insurers who assert that some services fall 

outside of the scope of benefits covered under MHPAEA, such as residential services for 

an inpatient benefit. APA believes that this position is not in line with the stated intent of 

the law and will prove to be dangerous for many patients who will not be able to afford 

complete treatment. This is particularly true with respect to coverage for alcohol and 

substance use disorder treatment and pediatric services which would be targeted through 

these policies. We recommend that the Departments take a close look at these insurance 

practices and clearly define the scope of services in the forthcoming regulations to avoid 

potential harm to a vulnerable population. 

APA has been working with our members to gather information these changes that 

insurers are making and is prepared to offer examples of discriminatory practices. Thank 

you for your consideration of these comments and we look forward to working with the 

Departments of Labor, Health and Human Services, and Treasury on these important 

issues in the future. If you have any further questions, please contact Jennifer Tassler, JD, 

Deputy Director, Regulatory Affairs, at jtassler@psych.org or at (703) 907-7842. 

Sincerely, 

James H. Scully Jr., M.D. 

Medical Director and C.E.O., American Psychiatric Association