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May 26, 2009 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

Attention: CMS-4137-NC 

PO Box 8017 

Baltimore, MD 21244 

RE: Paul Wellstone & Pete Domenici Mental Health Parity & Addiction Equality Act of 

2008 (Public Law 110-343) 

To Whom It May Concern: 

On behalf of the United States Psychiatric Rehabilitation Association (USPRA), I want to thank you 

for the opportunity to express our views about the Paul Wellstone & Pete Domenici Mental Health 

Parity & Addiction Equality Act of 2008 (the “Act”). USPRA is a nation-wide association of 1,400 

psychiatric rehabilitation agencies, practitioners, and interested organizations and individuals who 

are dedicated to promoting and strengthening community-oriented rehabilitation services that 

support recovery from the disabling effects of serious mental illness. 

For over thirty years, USPRA member organizations have provided an array of community-based, 

rehabilitation and recovery-oriented services to persons experiencing significant behavioral health 

symptoms. Based upon the collective experience of our members, we offer the following 

comments. 

Our first over-arching observation and concern is that the private insurance sector has severely 

limited experience with services based upon psychosocial rehabilitation goals, values and 

principles. Most private insurers only cover hospital-based acute care and traditional outpatient 

services. If day services are allowed, they are not rehabilitation oriented but, rather, day treatment 

programs focused exclusively on symptom alleviation. In order for services to be truly equitable, 

insurers must expand coverage for an array of rehabilitation programs, including both facility-based 

and in-home services. 

Our second observation is that the private sector does not promote the use of alternatives to 

hospitalization and other institutional 24-hour care settings. Specifically, crisis residential treatment 

programs provide comparable, if not better, outcomes than hospital-based acute care, at 1⁄3 to 1⁄2 the 

cost ($300 per day v. $1000 per day). This is important in the context of calculating cost 

exemptions. Benefit packages that utilize such alternatives will be significantly less expensive than 

the traditional hospital-based benefit. 

In addition the above general observations, USPRA has identified specific responses to the request 

for information surrounding Public Law 110-343: 
USPRA Public Comment 

Paul Wellstone & Pete Domenici Mental Health Parity & Addiction Equity Act of 2008 

Public Law 110-343 

Page 2 of 4

1. Treatment Limitation:

A. Coverage of Mental Health Illness Diagnoses: Regulation must be created specifying which 

diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) will be 

mandatorily covered under the Act. It is our interpretation of the Act that all diagnoses under the 

DSM will be covered. If this coverage is left open to interpretation, there will be extreme disparity 

from plan to plan, as well as state to state. Consumers, enrollees, and employers must be able to 

understand what mental health diagnoses will be part of their coverage. 

Many state health care plans and insurers currently have “treatment limitations” based upon their 

respective parity law, which officially mandates treatment of only ten diagnoses in the DSM. Plans 

and insurers may reimburse for treatment above and beyond the statutorily mandated ten diagnoses. 

The problem with this open ended ability of plans and insurers to cherry pick the diagnoses which 

they cover is that the variance is immense and there is no consistency. Consumers, enrollees, and 

employers are left to self-educate on the treatment limitations of their coverage. Putting forward 

clear language in regulation as to which diagnoses fall under the Act’s treatment limitations is 

absolutely necessary. 

B. Utilization Review: Health care plans and insurers have “utilization review” policies to 

assess treatment limitations on individual enrollees. Generally speaking, mental health and 

substance use treatments are placed under heavier scrutiny than medical/surgical treatments. 

Unfortunately, in practice, some insurers/plans will place a limit on the number of mental health 

visits when none exist in the contract. Clear language must be included in regulation as to the 

plan’s/insurer’s responsibility to adhere to the Act and not place treatment limitations on their 

enrollees’ access to medically necessary mental health or substance abuse treatment. 

2. Term Clarification:

A. Mental Health Illness and Substance Abuse Disorder: Regulation must clarify that the 

purpose of the Act is to serve both those suffering from mental health illnesses and substance abuse 

disorders. All three amendment sections: (a)-ERISA, (b)-Public Health Service Act, and (c)-IRS 

Code at sub-section (3) state: 

(3) Financial Requirements and Treatment Limitations. 

(A) IN GENERAL—In the case of a group health plan (or health insurance 

coverage offered in connection with such a plan) that provides both medical and 

surgical benefits and mental health or substance use disorder benefits, such plan or 

coverage shall ensure that— 

(i) the financial requirements applicable to such mental health or substance use 

disorder benefits are no more restrictive than the predominant financial 

requirements applied to substantially all medical and surgical benefits covered by 

the plan (or coverage) and there are no separate cost sharing requirements that are 

applicable only with respect to mental health or substance use disorder benefits; 

and, 

(ii) the treatment limitations applicable to such mental health or substance use 

disorder benefits are no more restrictive than the predominant treatment limitations 

applied to substantially all medical and surgical benefits covered by the plan (or 

coverage) and there are no separate treatment limitations that are applicable only 

with respect to mental health or substance use disorder benefits. 
USPRA Public Comment 

Paul Wellstone & Pete Domenici Mental Health Parity & Addiction Equity Act of 2008 

Public Law 110-343 

Page 3 of 4

Although the legislative intent behind the bill is to serve both those suffering from mental illness 

and substance abuse disorders, the way the language is currently written is open to interpretation by 

health care plans and insurers, as well as each individual state. Our recommendation is to clarify, 

through regulation, that Public Law 110-343 is to cover both mental health illness and substance 

abuse disorders, not either. 

B. Preliminary Diagnosis: Through regulation, it must be clear that the initial mental health 

provider’s diagnosis, the preliminary diagnosis, stands until another mental health provider declares 

otherwise. Plans and/or insurers routinely, and inappropriately, void the initial provider’s 

preliminary diagnosis without provider input (knocking the patient out of parity coverage.) Clarity 

needs to be given that the preliminary provider’s diagnosis stands until another provider amends 

that diagnosis (not the plan or insurer.) 

C. DSM-Scope of Mental Illness: Clarification within regulation that the entire DSM is 

covered by the Act is essential. See prior discussion under “Treatment Limitation” heading. 

3. Medical Necessity:

Currently, each plan and insurer creates its own medical necessity criteria. For obvious reasons this 

creates a lack of consistency, as well as a lack of clarity. It is imperative that there be a federal 

model put forward defining “medical necessity” so that the provider, the enrollee, and the consumer 

can all comprehend whether “medical necessity” applies to their mental health or substance abuse 

situation. In putting forward a model, it is crucial that the definition be created and vetted by all 

stakeholders, including mental health providers and consumers in addition to health care plans and 

insurers. 

Moreover, medical necessity criteria is not generally made readily available to the enrollee, but only 

to the providers. Putting forth regulation encouraging transparency as to medical necessity criteria 

would be beneficial to the enrollee and consumer. 

Lastly, creating an independent medical review system (“IMRS”) to evaluate contested denials of 

treatment based on “medical necessity” would protect the patient from inappropriate or unlawful 

plan or insurer denials of coverage based on medical necessity. Sample IMRS guidelines and 

principals can be further reviewed at California Health and Safety Code section 1374.30. 

4. Denial of Reimbursement or Payment:

Providing to the patient, and the health care practitioner, the reasoning behind a denial of 

reimbursement or payment is essential in protecting a patient’s right to treatment. In California for 

example, throughout the California Health & Safety Code and Insurance Code, language is utilized 

to mandate clear reasoning behind plan or insurer decision making. We would suggest mimicking 

this language in federal regulation such as: If reimbursement or payment is denied by the health 

care plan/insurer, the decision shall be in writing, and shall include a clear and concise 

explanation of the reasons for the decision. 
USPRA Public Comment 

Paul Wellstone & Pete Domenici Mental Health Parity & Addiction Equity Act of 2008 

Public Law 110-343 

Page 4 of 4

5. Out-of-Network Coverage:

Allowing the patient to receive services out-of-network is often necessary based on exigent 

circumstances. Putting into regulation the following concepts protects the patient, while not 

creating undue hardship on the health care plan or insurer: 

• For continuity of care purposes, if the patient’s plan/insurance changes, allow patient to 

continue with their existing behavioral health care practitioner, provided that practitioner is 

willing to accept the new health care plan/insurer’s rate of reimbursement; 

• To assure timely access to care, if an in-network provider is not available to a patient within 

a timely manner, the plan/insurer shall reimburse the out-of-network practitioner; 

• To assure timely access to care, if an in-network provider is not available to a patient within 

their geographic area within a timely manner, the plan/insurer shall reimburse the out-ofnetwork practitioner; 

• A definition of “timely access to care” needs to be developed and vetted by stakeholders 

including mental health providers and consumers, as well as health care plans and insurers; 

and, 

• Plan/insurer to reimburse for any reasonable costs associated with urgent care or emergency 

services, or other extraordinary and compelling health care services, when the patient’s 

decision to secure those services outside of the plan network was reasonable under the 

urgent or emergency circumstances; 

6. Cost Exemptions:

Model notices would be helpful in facilitating disclosure to agencies, enrollees and beneficiaries 

regarding the plan or insurer’s election to implement the cost exemption. In addition, regulation 

should be adopted mandating that the plan or insurer notify the enrollees and beneficiaries before 

they elect to take the cost exemption so that those directly affected by the exemption have the 

ability to select other coverage that includes their given diagnoses. Additionally, regulation should 

mandate strict enforcement of plan/insurer reapplication for cost-exemption so that plans/insurers 

cannot continue with exemption without cause. Lastly, whatever evidence a plan/insurer utilizes to 

support an application for exemption should be transparent to the consumer so that advocacy groups 

may appeal or rebut a flawed application. 

In our earlier remarks, we noted the implications of plans that utilized alternatives to hospital and 

other institutional-based 24-hour care. The cost implications are obvious but it should also be noted 

that among all the research studies on alternatives to hospital-based acute care, there is no case 

where the outcomes of hospitalization were more positive than alternative treatment. 

Thank you for your attention to this matter and please let us know if we can provide you any 

additional information. 

Sincerely, 

Marcie Granahan 

CEO