1127 – 11th Street, Suite 925, Sacramento, CA 95814 

(916) 557-1167 TEL (916) 447-2350 FAX mail@mhac.org EMAIL www.mhac.org WEBSITE 

C:\Documents and Settings\gelman.beth\Local Settings\Temporary Internet Files\OLK28\CCMH Parity Response to Federal 

Register.doc 

 VIA E-MAIL: E-OHPSCA.EBSA@DOL.GOV 

 May 27, 2009 

 U.S. Department of Labor 

 Employee Benefits Security Administration 

 200 Constitution Avenue, N.W., Room N-5653 

 Washington, D.C. 20210 

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 California Coalition for Mental 

Health (CCMH), we wish to thank you for the 

opportunity to express our views about the Paul 

Wellstone & Pete Domenici Mental Health Parity & 

Addiction Equality Act of 2008 (“Act”). 

CCMH is comprised of over thirty organizations 

whose membership includes family members and 

consumers, and professional as well as 

institutional providers of mental health. 

In the text below, CCMH has identified specific 

responses to the request for information 

surrounding Public Law 110-343: 

1. Treatment Limitation:

American Association for Marriage and 

Family Therapy California Division 

California Alliance of Child and Family 

Services 

California Association of Health 

Facilities 

California Association of Marriage and 

Family Therapists 

California Association of Mental Health 

Patients Rights Advocates 

California Association of Social 

Rehabilitation Agencies 

California Council of Community 

Mental Health Agencies 

California Hospital Association 

California Institute for Mental Health 

California Mental Health Advocates for 

Children and Youth 

California Mental Health Directors 

Association 

California Mental Health Planning 

Council 

California Network of Mental Health 

Clients 

California Primary Care Association 

California Psychiatric Association 

California Psychological Association 

California Society for Clinical Social 

Work 

California Women’s Mental Health 

Policy Council 

Disability Rights California 

Mental Health Association in California 

Mental Health Association of Santa 

Barbara 

NAMI California 

National Association of Social Workers, 

California Chapter 

Occupational Therapy Association of 

California, Inc. 

Orange County Coalition for Mental 

Health 

San Diego Coalition for Mental Health 

Service Employees International Union, 

Local 1021 

Suicide Prevention Advocacy Network, 

California 

United Advocates for Children and 

Families 
1127 – 11th Street, Suite 925, Sacramento, CA 95814 

(916) 557-1167 TEL (916) 447-2350 FAX mail@mhac.org EMAIL www.mhac.org WEBSITE 

C:\Documents and Settings\gelman.beth\Local Settings\Temporary Internet Files\OLK28\CCMH Parity Response to Federal 

Register.doc 

Health care plans and insurers use “utilization review” 

policies to assess treatment limitations on individual 

enrollees. Generally speaking, mental health and 

CCMH 

Page 2 

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 use utilization review to place 

treatment limitations on their enrollees’ access to medically necessary 

mental health illness 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 subsection (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. 

CCMH 

Page 3 

A clear statement should be put into regulation advising 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 with the result in California of depriving the 

individual of the benefits of California’s parity law. Clarity needs to be given 

that the preliminary provider’s diagnosis stands until another provider 

amends that diagnosis (not the plan or insurer.) 

3. Medical Necessity: 

Currently, each plan and insurer creates their 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. Medi-Cal and Medicare have 

both put forward “medical necessity” criteria definitions which may be useful 

in developing model language. 
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. 

CCMH 

Page 4 

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. 

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 similar language in 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. 

5. Out-of-Network Coverage: 

Allowing the patient to receive services out-of-network may sometimes be 

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 health care 

practitioner (even if out-of-network), 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-of-network 

practitioner; 

• A definition of “timely access to care”; 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 

CCMH 

Page 5 

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, the plan or insurer should 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 which includes their given diagnosis. 

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 available to the consumer so that advocacy groups 

may appeal or rebut a flawed application. 

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

provide you any additional information. 

Sincerely, 
Mary Riemersma 

President