National Association of State Mental Health Program Directors 

66 Canal Center Plaza, Suite 302, Alexandria, VA 22314 (703) 739-9333 Fax (703) 548-9517 

OPERATING UNDER A COOPERATIVE AGREEMENT WITH THE NATIONAL GOVERNORS ASSOCIATION 

NASMHPD 

 Board of Directors 

Virginia Trotter Betts, M.S.N., J.D., 

R.N., F.A.A.N. 

 President

 Tennessee 

Kevin Martone, M.S.W. 

 Vice President 

New Jersey 

 

Lorrie Rickman Jones, Ph.D. 

 Treasurer 

Illinois 

Brian Hepburn, M.D. 

Secretary 

Maryland 

Joan Erney, J.D. 

At-Large Member 

Pennsylvania 

North-Eastern Regional 

Representative 

Laura Nelson, M.D. 

Western Regional 

Representative 

Arizona 

Terri White, M.S.W. 

Mid-Western Regional 

Representative 

Oklahoma 

Katharine Lyon, Ph.D. 

Southern Regional 

Representative 

Florida 

Robert W. Glover, Ph.D. 

Executive Director 

NASMHPD 

May 3, 2010 

Internal Revenue Service 

Department of the Treasury 

Employee Benefits Security Administration 

Department of Labor 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

RE: Interim Final Rules under the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act of 2008 (published in 75 Fed. Reg. 5410 

et seq.) 

RIN 1210-AB30 

Via Email: E-OHPSCA.EBSA@dol.gov

To the Departments: 

The National Association of State Mental Health Program Directors (NASMHPD) 

appreciates the opportunity to comment of the interim final rule (“IFR”) for the 

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 

Act of 2008 (“MHPAEA”), as published in the February 2, 2010 Federal Register. 

NASMHPD, representing the mental health authorities in the 50 states, 4 

territories and the District of Columbia, strongly supported the passage of the 

parity law and believes these regulations adhere to both the letter and spirit of the 

law. We also believe the process of issuing a request for information and an IFR 

provided sufficient opportunity for public comment and was in the public interest.

The $34 billion public mental health system serves over 6 million people 

annually. Most of these individuals are adults with serious mental illness or 

children with serious emotional disturbances. A tragic reality for many 

individuals in the public mental health system is a dramatically shortened lifespan 

due in large part to preventable, chronic conditions. The implementation of the 

parity law has the potential to foster early intervention and mitigate the worse 

effects of serious mental illness, increasing the opportunity for healthy and 

productive lives for many. As stated in the regulation, providing coverage for 

mental health and substance use disorders will mean more people obtain the care 

they need and fewer will exhaust benefits and resort to the public sector for 

services. 
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May 3, 2010 

Prohibition against separate deductibles or other cumulative financial requirements 

We applaud the departments for their choice to require combined deductibles, out-of-pocket 

maximums or other cumulative financial requirements on mental health and substance use 

disorder benefits. A prohibition against separate deductibles will greatly improve access to 

mental health and substance use services and will remove barriers to receiving quality care in the 

most appropriate setting. A combined deductible requirement is consistent with the goal of the 

parity law to end discriminatory practices that negatively impact people who need both general 

healthcare and mental health and/or substance use disorder services. This policy advances 

comprehensive healthcare that includes mental health and substance use disorder (MH and SUD) 

services. 

Parity standard that ensures non-discrimination in mental health and substance use 

benefits 

NASMHPD believes that the classifications of benefits (inpatient/in-network, inpatient/out-ofnetwork, outpatient/in-network, outpatient/out-of-network, emergency care and prescription drug 

coverage) in which parity is applied are clear and inclusive and the requirement that parity 

applies in all classifications is correct and workable. We also support the prohibition on creating 

additional and separate classifications where parity would not apply. 

We concur with the definition of nonquantitative treatment limitations and the requirement that a 

range of services cannot be applied more restrictively or more stringently to MH/SUD than 

medical/surgical. While the preamble states that scope of services is not addressed in the rule, 

the application of nonquantitative treatment limitations requires comparability between 

MH/SUD benefits and medical/surgical. Nevertheless, we request clarification on the 

application of the MHPAEA to scope of services beyond the requirement of parity for 

nonquantitative treatment limitations. 

We encourage the departments to provide additional examples to illustrate the application of the 

nonquantitative treatment limitation rule to other features of medical management or general 

plan design. We are concerned that a strict application of a “medical necessity” standard will 

result in coverage denials for mental health and substance use disorder benefits that are effective. 

Reliance on “recognized clinically appropriate standards of care” as described in the regulation is 

preferable to a “medical necessity” standard that could result in inappropriate coverage denials. 

The regulation permits one exception to the requirement that nonquantitative treatment 

limitations be comparable and applied no more stringently and that is when “recognized 

clinically appropriate standards of care” permit a difference. There must be adequate 

requirements for determining when a standard is recognized as clinically appropriate. The 

process must not be an internal process involving a plan’s own consultants and employees but 

must include external verification and the involvement by consumers, stakeholders, experts, and 
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May 3, 2010 

national and local organizations. A standard for determining whether a treatment is 

experimental, for example, would not be acceptable if it required controlled clinical trials for 

mental health and substance use disorders but allowed consensus panels for medical/surgical 

treatments. 

As the health care system retools to pay for outcomes, the benefit packages for both 

medical/surgical and MH/SUD are likely to include a broader array of services to promote health 

and recovery. Such services could include case management, habilitation, illness selfmanagement and supportive services related to education, employment, and housing. As a basic 

level of wellness and preventive services are provided on the medical/surgical side, it will be 

important to develop and cover the behavioral health equivalents to vaccinations and 

inoculations. 

Categorizing mental health providers as specialists 

We urge the departments to address in the regulation itself the classification of mental health 

providers as specialists for the purpose of determining co-pay levels. It is especially important 

for the copayment for outpatient psychotherapy visits to be comparable to co-pays for visits to 

primary care physicians. Otherwise, many individuals will forego services and seek services 

from less appropriate (and possibly more expensive) providers and outcomes will suffer. 

Provider Networks 

NASMHPD strongly supports the development of standards to ensure the adequacy of providers 

in the networks. As the demand for services increases as more people obtain insurance coverage 

under health reform, it will be important to monitor whether networks for both primary and 

specialty care are adequate to meet the demand. 

Formulary Design 

The regulations state that a plan satisfies the parity requirement if it applies different levels of 

financial requirements to different tiers of benefits based on reasonable factors such as cost, 

efficacy and generic vs. brand and “without regard to whether a drug is generally prescribed with 

respect to medical/surgical or with respect to mental health or substance use disorder benefits...” 

It is important that cost not be the exclusive criteria in coverage determinations. There is some 

evidence that the coverage standards for brand name drugs for certain mental health and 

substance use disorders are more stringent than on the medical/surgical side. The regulations 

should specify that brand name drugs should be available if there is not a comparable generic 

drug available. 

Conclusion 

 
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May 3, 2010 

As parity is implemented, it will be important for the departments to carefully monitor how many 

plans drop mental health and substance use disorder benefits rather than comply with parity 

requirements and whether plans exempt coverage for specific conditions or disorders (e.g., 

schizophrenia). It also will be important to assess the impact of covering mental health and 

substance use disorders on overall medical costs. NASMHPD appreciates the departments’ 

efforts to date to realize the promise of the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act of 2008. 

Sincerely yours, 

Robert W. Glover, PhD 

Executive Director 

National Association of State Mental Health Program Directors