Docket: EBSA-2009-0010 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Comment On: EBSA-2009-0010-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0249 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Roger Schwartz 

Address: 

1400 Eye Street NW, Suite 330 

Washington, DC, 20005 

Email: rschwartz@nachc.com 

Phone: 202-296-0158 

Organization: National Association of Community Health Centers 

General Comment 

May 28, 2009 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Attention: CMS – 4137-NC 

P. O. Box 8017 

Baltimore, MD 21244-8010 

RE: Request for Information Regarding the Paul Wellstone and Pete Domenici 

PUBLIC SUBMISSION 

As of: May 29, 2009 

Received: May 28, 2009 

Status: Pending_Post 

Tracking No. 809bc72a 

Comments Due: May 28, 2009

Submission Type: Web
Mental Health Parity and Addiction Equity Act of 2008 

To Whom It May Concern: 

The National Association of Community Health Centers (NACHC) is pleased to 

respond to the above-cited solicitation from the Departments of Health and Human 

Services (HHS), Department of Labor, and the Treasury. NACHC is the national 

membership organization for federally-supported and federally recognized health 

centers (FQHCs) throughout the country, and is an Internal Revenue Code 

Section 501(c)(3) organization. NACHC also serves as a source of information, 

analysis, research, education, training, and advocacy regarding medically 

underserved people and communities. 

BACKGROUND 

There are approximately 1,200 health center entities nationwide, which serve as 

the health care homes to more than eighteen (18) million persons at more than 

7,000 sites located in all fifty (50) states, Puerto Rico, the District of Columbia, 

the U.S. Virgin Islands and the Pacific Islands. Most of these health centers 

receive federal grants under Section 330 of the Public Health Service Act (42 

U.S.C. §254b) from the Bureau of Primary Health Care (BPHC), within the Health 

Resources and Services Administration (HRSA). 

BPHC’s grants are intended to provide funds to assist health centers with the 

costs of providing a continuum of comprehensive preventive and primary care 

(including medical, behavioral health, dental, and pharmaceutical) and enabling 

services to uninsured and underinsured low-income patients, as well as to 

maintain the health center’s infrastructure. Patients from eligible communities 

who are not low-income or who have insurance (whether public or private) are 

expected to pay for the services rendered. Approximately 15% of the patients 

served by health centers have private insurance, approximately 39% are 

uninsured, approximately 35% are Medicaid/SCHIP recipients, approximately 8% 

are Medicare beneficiaries, and approximately 3% are covered by other public 

sources 1. 

FQHCs are required to make services available to all residents of their service 

area. See 42 U.S.C. §§ 254b(a)(1) 2. FQHCs must be located in or serve a 

federally-designated Medically Underserved Area (MUA) or Medically Underserved 

Population (MUP). Additionally, a substantial number of health centers are 

located in or serve an area, population or facility that has been designated as a 

Health Professional Shortage Area (HPSA). 

COMMENTS 

FQHCs have long recognized that behavioral health conditions - including mental 

health and substance use disorder services – influence a patient’s overall health 

status. Therefore, high-quality, accessible, and culturally competent early and 

sustained behavioral health services spanning the lifecycle of patients are a 

critical component of FQHCs’ effective comprehensive preventive and primary 

health care and are critical in controlling the cost of health care. FQHCs 

recognize the need for incorporating behavioral health screening and treatment 
with management of chronic conditions. Managing co-occurring behavioral health 

and chronic diseases can improve both physical and behavioral health 3. FQHCs 

are critical sources of behavioral health services to those with the highest unmet 

needs. Indeed, mental health and substance abuse related conditions are a major 

reason for patient visits to a FQHC. This is especially true in rural areas of 

America where FQHCs might be the only available source of health care – for 

primary care and for behavioral health services. 

NACHC is concerned that health managed care companies refuse to include 

FQHCs on their provider panels and will not allow FQHC providers to join their 

network because the companies maintain that the FQHC is not a “licensed Mental 

Health agency” or a licensed provider in “independent practice.” However, the 

behavioral health professionals that are employees or contractors of the FQHC are 

licensed professionals credentialed in their specialties and held to 

rigorous “evidence-based” performance and accountability requirements by the 

FQHC’s Board of Directors, state laws, and the Health Resources and Services 

Administration (HRSA) of the Health and Human Services Administration (HHS). 

Nearly every FQHC provides behavioral health treatment and counseling services 

on site or through formal referral arrangements. Behavioral health staff include 

psychiatrists, clinical/counseling psychologists, clinical social workers, marriage 

and/or family therapists, psychiatric nurse specialists, and licensed professional 

counselors. The FQHC bills insurers and plans for all services provided by FQHC 

staff. 

Related to the concern mentioned above, if there is a behavioral health carve out, 

the behavioral health managed care company often does not recognize the 

services that are provided by the FQHC as the FQHC is out-of-network. As noted 

above, if the FQHC tries to have its staff become part of the network, they are told 

the network is closed. The managed care company is not refusing treatment; 

however, they are not paying for treatment in settings where the patient is seeking 

and receiving treatment. This presents a challenge to FQHCs who have an ethical 

commitment to treat all patients’ behavioral health needs as integral to 

comprehensive health care, but struggle with reimbursement issues. 

NACHC recommends that: 

• Plans enroll and reimburse FQHCs directly as “essential community 

providers” of mental health and substance use disorders and allow all 

appropriately licensed behavioral health clinicians to provide and be reimbursed 

for services 

• Plans do not require providers to be in-network for coverage and 

reimbursement 

• Plans permit out-of-network mental health and substance use disorder 

coverage and reimbursement as they permit out-of-network medical/surgical care 

coverage and reimbursement 

• Plans permit patients be allowed to remain with the same practitioner 

and/or FQHC if a patient’s plan changes. This enhances continuity of care 

benefits. 

• Plans cover all evidence-based mental health and substance use 

disorder services and not “pick” only certain diagnoses or treatments 

• Plans cover unlimited visits as they do for medical and surgical 

conditions 
• Plans not charge greater co-pays for out-of-network providers 

Thank you for the opportunity to comment on this Request for Information. If you 

have any questions about the contents of this document, please call or email me 

at 202-296-0158; rschwartz@nachc.com . 

Sincerely, 

Roger Schwartz 

Associate Vice President of Executive Branch Liaison 

1. In addition to those health centers receiving grant funds pursuant to one or 

more of the Section 330 funding programs, there are certain entities that are 

designated by the Centers for Medicare and Medicaid Services (CMS) as FQHCs, 

by virtue of the fact that they meet all of the requirements to receive a Section 330 

grant, but do not receive funding from HRSA. For purposes of this comment, 

unless otherwise noted, we do not distinguish between grantees and FQHC lookalike entities, collectively referring to both types of organizations as “FQHCs” 

or “health centers.” 

2 There are certain exceptions to this requirement for health centers that receive 

grant funds solely to serve migrant and seasonal farm workers, homeless 

individual and families, and/or residents of public housing. 

3 Simon G. “Psychiatric Disorder and Functional Somatic Symptoms as 

Predicators for Health Care Use.” 1992 Psychiatric Medicine 10:49-60.