NAADAC-NAATP Government Relations Department · 1001 N. Fairfax St. Ste. 201 · Alexandria, VA 22314 

P 703.741.7686 x129 · F 703.741.7698 · www.naatp.org · www.naadac.org 

May 28, 2009 

Office of Health Plan Standards and Compliance Assistance 

Employee Benefits Security Administration 

United States Department of Labor 

Room N-5653 

200 Constitution Ave. NW 

Washington, D.C. 20210 

Attn: MHPAEA Comments 

Dear Sir or Madam: 

We are writing in response to the Request for Information (RFI) issued April 28, 2009 as part of 

the regulations-writing process for the Paul Wellstone and Pete Domenici Mental Health Parity 

and Addiction Equity Act (MHPAEA). On behalf of our memberships, we thank you for the 

opportunity to aid in the development of the MHPAEA regulations by providing the background 

information requested in the RFI. 

NAADAC, the Association for Addiction Professionals is the primary association for addictionfocused counselors, educators and other health care professionals. We have 10,000 members and 

affiliates in 47 states. NAADAC’s mission is to lead, unify and empower addiction professionals 

through education, advocacy, ethics, professional standards and research. 

The National Association of Addiction Treatment Providers (NAATP) is the primary trade 

association for private addiction treatment programs. We represent over 300 members across the 

United States, Mexico and Canada. NAATP’s mission is to promote, assist and enhance the 

delivery of ethical, effective and research-based treatment for alcoholism and other drug 

addictions. 

NAATP and NAADAC work in partnership on public policy issues. In order to provide the most 

accurate information possible, we conducted an informal survey of our members’ experiences 

with the issues raised in the RFI; over 50 programs and professionals from across the country 

participated. We have included a sampling of their comments, arranged in the same format of 

this letter, as Attachment A. The full list of the respondents can also be found in Attachment A. 

Page 1 of 7 

NAADAC-NAATP MHPAEA RFI Response 

May 28, 2009 
Page 2 of 7 

NAADAC-NAATP MHPAEA RFI Response 

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It is our hope that this information provides you with a better understanding of the way that 

insurance coverage of addiction treatment affects the way that care is provided in the field. 

1. Financial Requirements, Treatment Limitations and Addiction Treatment 

There are several significant ways in which treatment limitations and financial requirements for 

addiction services differ from other medical treatment. 

A. Residential Versus Inpatient Treatment. Many health plans that include an 

“inpatient” treatment benefit only cover inpatient services in acute care hospitals, not 

in sub-acute residential addiction treatment programs. Residential treatment is a more 

appropriate treatment setting than a hospital for many patients. Residential treatment 

allows for more comprehensive and structured treatment models than are often 

available in inpatient acute care settings. Such programs hold national accreditations 

(often the same accreditations that hospitals use) and state licenses. 

B. Limits on the Number or Types of Services per Day. Some health plans impose 

limits on the number or type of sessions that may be provided on the same day. For 

example, some patients in outpatient programs are not allowed to be seen for an 

individual counseling session and a group session the same day. 

C. Pre-Existing Condition Exclusions. Loosely defined pre-existing condition 

exclusions risk invalidating most substance use disorder and mental health coverage. 

Both sets of disorders are chronic conditions, and most people only seek treatment 

long after the onset of the disease (people who seek treatment for alcohol dependence, 

for example, begin treatment an average of ten years after the disease’s onset).1

Insurance plans should explicitly exempt substance use disorders and chronic 

psychiatric conditions from their pre-existing conditions exclusion. 

D. Court-Ordered Treatment Exclusions. Many health plans explicitly exclude 

coverage of medical services if they are court-ordered. This exclusion affects 

treatment for substance use disorders and mental illness almost exclusively (other 

court-ordered treatment would include exceptional cases involving medical 

interventions on children and disabled adults when it is opposed by their guardians 

and certain situations involving the termination of life-sustaining treatment). Thus 

this exclusion is a de facto and discriminatory limitation against treatment for 

substance use disorders and mental illness. It goes strongly against the intent of the 

MHPAEA. 

If a given treatment is deemed medically necessary by a treating physician and 

covered under the benefit plan, there is no reason that it should be excluded because 

1

 NIH News. 2 July 2007. “Survey Reveals ‘Lost Decade’ Between Ages of Disorder Onset and Treatment.” 

http://www.nih.gov/news/pr/jul2007/niaaa-02.htm. 
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NAADAC-NAATP MHPAEA RFI Response 

May 28, 2009 

                                                           

the beneficiary was referred by a court. Beneficiaries expect their plans to cover all 

medically necessary care included in their benefit, and court-ordered treatment has 

been demonstrated to be at least as effective as non-court-ordered treatment.2

 Some 

states (such as Colorado and Minnesota) have already taken steps to ensure that 

people referred to treatment as a result of the legal process can access their benefits. 

E. Alcohol and Drug Trauma Exclusions. Many health plans will deny reimbursement 

to providers (particularly in emergency departments and trauma centers) that treat 

individuals who were using alcohol or other drugs at the time of their injury. (In some 

cases, up to half of people admitted to emergency departments are there for reasons 

related to alcohol or other drug use.) At one time more than half of the states allowed 

such exclusions, although more recently several states have repealed these laws. 

Alcohol and Drug Trauma Exclusions not only discriminate against people in need of 

addiction treatment, but they also provide the perverse incentive for treating clinicians 

to avoid screening for drug or alcohol use. This means that people may not receive 

the most appropriate care possible at the time of their injury, and it almost certainly 

means that window of time between the onset of the disease and its treatment will be 

extended. 

F. Requirement to Complete Treatment. Some health plans will not reimburse 

providers for any services they provide unless the patient completes the entire course 

of treatment. If the patient receives inpatient treatment, for example, but then does not 

complete the outpatient visits required, the inpatient treatment program may not be 

reimbursed. Often, patients do not complete treatment because the financial 

obligations become too great or it is too logistically difficult for them to do so. In 

practice, the requirement to complete treatment is discriminatory to the extent that it 

affects substance use disorder and mental health treatment more than most other 

medical services. Health benefits should cover any addiction services that are deemed 

medically necessary at the time they are provided regardless of whether the 

beneficiary later decides to stop their treatment. 

2. Terms and Definitions 

A. The intent of the MHPAEA is that the term “parity” refers to treatment of both mental 

health conditions and substance use disorders. A plan cannot provide parity only for 

mental health benefits or only for substance use disorder benefits and be considered in 

compliance. This applies with respect to both in-network and out-of-network benefits. 

B. If a plan chooses to suspend parity because of the cost exemption clause in the 

MHPAEA, it must issue notification to all plan participants informing them of the 

change. This process should be outlined in the regulations. 

2

 National Institute on Drug Abuse (2006). “Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide,” p 

18. Available online: http://www.nida.nih.gov/PODAT_CJ/faqs/faqs1.html#5. 
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NAADAC-NAATP MHPAEA RFI Response 

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C. Previous studies of state-level parity have demonstrated that extensive public 

education and consumer outreach is essential to realize parity’s potential. The 

Secretaries of Labor, the Treasury and Health and Human Services should be required 

to establish a website and toll-free hotline for use by consumers and providers to 

report denials of benefits protected by the MHPAEA. Both the website and hotline 

should offer information about the rights of plan participants under the MHPAEA and 

provide resources that would enable them to appeal their plans’ decisions and pursue 

alternative treatment services immediately, if needed (for example, through publicly 

funded programs). Similarly, a notice in writing from the Secretaries should be 

provided to each plan participant summarizing the changes in mental health and 

substance use disorder benefits under the MHPAEA. A public service announcement 

campaign (using as many different forms of media as possible) should be undertaken 

as well to educate the public about the MHPAEA and encourage people to seek 

treatment if needed. 

D. State laws that provide stronger protections for people in need of mental health or 

substance use disorder services should be protected—the MHPAEA sets a federal 

“floor,” not a “ceiling.” The MHPAEA should not pre-empt state laws (such as 

Pennsylvania’s) that have mandated minimum treatment limits for state-regulated 

plans. The pre-emption language could mirror applicable language in the HIPAA 

privacy regulations 45 CFR 160.202-205. 

E. “Parity” as defined in the MHPAEA means that treatment limitations and financial 

requirements for mental health and substance use disorder benefits must be “no more 

restrictive” than medical limitations and requirements. However, mental health and 

substance use disorder benefits may be less restrictive than other medical benefits. 

F. “Financial requirements” in the MHPAEA include the cost-sharing between plans and 

participants regarding prescription medication that is part of a beneficiary’s mental 

health or substance use disorder treatment plan. 

G. “Substance use disorder benefits” include the full range of treatment interventions 

appropriate for people with substance use disorders, including assessment, 

stabilization, detoxification, outpatient treatment, intensive outpatient treatment, 

partial hospitalization, inpatient residential treatment, medication-assisted treatment 

and recovery support services. 

3. Medical Necessity Criteria 

A. The medical necessity criteria used by different health plans vary significantly. Many 

(but certainly not all) criteria are based on the American Society of Addiction 

Medicine’s Patient Placement Criteria (ASAM PPC); however, the use and 

interpretation of the ASAM PPC are far from consistent from plan to plan. MHPAEA 

regulations could help clarify that treatment will be deemed medically necessary if 
Page 5 of 7 

NAADAC-NAATP MHPAEA RFI Response 

May 28, 2009 

prescribed by the treating physician in accordance with a clinically-based patient 

placement criteria. 

B. The availability of medical necessity criteria to providers varies significantly. In some 

cases, the criteria are available on the health plan’s provider portal website (which 

non-contracting providers cannot always access). In others, they are available to the 

provider upon request (some providers report being given the provisions by phone but 

not in writing). In other situations, however, the criteria are labeled “internal 

property” or “proprietary” and not shared with providers. In such cases, the patient is 

often forced to become the intermediary between the plan and the provider. 

C. The interpretation of medical necessity criteria often matter more than the criteria 

themselves. They are frequently written ambiguously and open to a great deal of 

interpretation by the plan. As part of the transparency requirements in the MHPAEA, 

plans should be required to provide all the information that would be needed for a 

beneficiary or provider to understand whether or not medical necessity criteria have 

been met for each level of mental health or substance use disorder treatment, 

including information about how the plan interprets its medical necessity criteria if 

necessary. Plans should also be required to provide advance written notice to plan 

administrators and beneficiaries when there are changes to the medical necessity 

criteria. 

D. Some health plans do not consider inpatient detoxification services for certain drugs 

medically necessary under any circumstances. This is an extremely selective and 

arbitrary use of medical necessity criteria. 

E. One of the most counterproductive uses of medical necessity criteria involves the 

requirement that a beneficiary fail at a less intensive level of care before being 

eligible for a given level of care, regardless of their symptomology. For example, 

many plans will require that someone attempt (and fail) at outpatient treatment before 

they can be admitted to a residential treatment program. This policy is perverse for 

patients who meet all the objective medical necessity criteria for residential treatment; 

it throws them back into an environment where their treatment is highly unlikely to 

succeed. In the meantime, they may be at high risk of having their situation worsen. 

Some plans require multiple failures at less intensive treatment before authorizing 

residential treatment. 

4. Reasons for Denial 

Reasons for denials are generally made available to the treatment provider. Possible 

reasons include: 

a. Failure to meet the plan’s internal medical necessity criteria 

b. Failure to obtain pre-authorization 

c. Level of care not included in benefits 

d. Exhaustion of benefits 
Page 6 of 7 

NAADAC-NAATP MHPAEA RFI Response 

May 28, 2009 

e. Court-ordered treatment exclusion 

f. Pre-existing condition 

g. Level of care not authorized without a treatment history that shows the patient 

failing at less intensive treatments (sometimes it is required that they fail more 

than once) 

An explanation of benefits (EOB) letter is normally sent by the insurance plan to the 

provider and beneficiary explaining the reason for denial (and spelling out the process 

for appeal). However, EOB letters are only available after treatment has already been 

denied. Further clarification of due process rights (perhaps modeled on 

Pennsylvania’s Act 106) would provide much-needed consumer protections for plan 

participants. 

5. Out-of-Network Coverage 

Some plans provide out-of-network coverage for addiction treatment. The financial 

burden that falls on a patient receiving out-of-network care is often significantly 

higher than if they received care in-network, and the payments to out-of-network 

providers are significantly lower. These costs can be prohibitive for many 

beneficiaries. Reimbursement for both providers and beneficiaries is often much 

slower than when a provider is in-network. When a provider is out-of-network, some 

treatment programs will try to negotiate “ad hoc” or “single-case” agreements with 

the insurance plans so that inpatient rates will apply—these arrangements are not 

always possible. 

An additional problem arises when a program is in an insurance provider’s network 

but not in a managed care company’s network. If a plan is managed by a managed 

care company that a treatment provider is not contracted with, then the treatment 

provider is out-of-network even if it is contracted with the insurance provider itself. 

This can lead to a great deal of confusion. 

Finally, as with other areas of health care, arbitrary limits on the number or type of 

providers allowed on panels forces some people to seek services out-of-network. 

Because plans’ financial requirements have historically been more burdensome for 

addiction services than other medical care, the added cost of going out-of-network for 

addiction treatment is an even greater barrier to care than it is for other medical 

services. The inability of beneficiaries—particularly in rural areas—to access 

treatment in their geographical area forces some people to choose between paying the 

higher out-of-network rates or foregoing treatment altogether. 

6. Additional Comments 

A. Reporting. The mandated Report to the Secretary of Labor should include the 

following data, itemized by diagnosis and age group, to provide the best possible 

picture of the MHPAEA’s effects: 
a. The number of beneficiaries seeking treatment for mental health conditions or 

substance use disorders 

b. The type and duration of care provided 

c. Reasons for denial of care 

d. The number and success rates of appeals 

e. A description of the educational and informational materials provided to plan 

participants describing their coverage under the MHPAEA 

f. The cost of care to the plan and the beneficiary 

g. The treatment settings in which services are delivered 

h. The change in the rates of usage and expenditures before and after the 

MHPAEA 

i. The number of plans that did not implement the MHPAEA and their reasons 

for not doing so (i.e. cost exemption, dropping mental health and substance 

use disorder benefits altogether, etc.) and the usage rates and expenditures of 

those plans’ participants on mental health and substance use disorder services. 

B. Enforcement. If the Report to the Secretary of Labor and the Government 

Accountability Office Study find that access to substance use disorder treatment 

decreases in a plan after it implements the MHPAEA, that should be interpreted as 

prima facie evidence of discrimination. The plan should face the burden of proof that 

it did not engage in discriminatory practices. The U.S. Department of Health and 

Human Services Office for Civil Rights should have the authority to conduct further 

investigations and impose penalties on such plans. 

C. Restrictions on Types of Professionals. Many insurance plans severely restrict the 

types of services that state-licensed, certified or otherwise qualified providers can 

perform. This significantly reduces access to substance use disorder services and 

increases the expense for both beneficiaries and providers. 

Once more, thank you for the opportunity to provide these comments on the MHPAEA. Please 

do not hesitate to contact us for additional information. 

Sincerely, 

    

Cynthia Moreno Tuohy, NCAC II, CCDC III Ronald J. Hunsicker, D.MIN, FACATA 

Executive Director, NAADAC President/CEO, NAATP 

 

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NAADAC-NAATP MHPAEA RFI Response 

May 28, 2009 
      

NAADAC-NAATP Government Relations Department · 1001 N. Fairfax St. Ste. 201 · Alexandria, VA 22314 

P 703.741.7686 x129 · F 703.741.7698 · www.naatp.org · www.naadac.org 

ATTACHMENT A 

In order to provide the most current and accurate information possible, the National 

Association of Addiction Treatment Providers (NAATP) and NAADAC, the Association 

for Addiction Professionals offered its members the opportunity to share their 

experiences with the issues addressed in the Request for Information (RFI). A ninequestion survey form based on the questions posed in the RFI was circulated to 

NAADAC and NAATP members. 

Selected excerpts from the responses are included below in support of the comments that 

we have provided. It is our hope that these quotations provide a valuable real-world 

perspective on the challenges that the current insurance system poses to both 

beneficiaries and addiction treatment programs. NAADAC and NAATP members are 

uniquely situated to explain how health plans’ benefits influence the way that addiction 

treatment is provided. 

Some of the quotations have been edited slightly for clarity; none have been edited to 

change their content. 

The full list of respondents can be found on page 8. 

1. Financial Requirements, Treatment Limitations and Addiction Treatment 

A. Residential Versus Inpatient Treatment: 

Some insurance companies have a reputation for only authorizing intensive outpatient and 

rarely authorizing residential. When we call, we know it is very unlikely the client will get 

residential no matter what information we provide. If residential is authorized, it is extremely 

limited and we have to begin immediately planning for discharge. 

- Eleventh Hour Rehabilitation Programs, Fresno, Ca. 

Because most insurance companies are unwilling to contract for residential services, we do 

not have a negotiated rate-per-day for services. This leaves the client responsible to pay 

whatever charges remain after the insurance company pays what they determine they are 

responsible for. Most customer service reps state that they do not know what the daily rate is, 

so the client is stuck trying to decide what they can pay without knowing what the insurance 

company is agreeing to pay. 

-Johnson County Mental Health Center, Olathe, Kan. 

Page 1 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 
Page 2 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

B. Limits on the Number or Types of Services per Day 

If a client is seen by two clinicians on the same day at the same organization, one will be 

denied as a duplicate. For example, if a client meets with an M.D. for a psychiatric evaluation 

then meets with a clinician for outpatient bio-psycho-social evaluation. 

-Chestnut Health Systems, Bloomington, Ill. 

Some plans will ask for the name of the attending physician for the patient’s care. They are 

given the name of the admitting physician. They will sometimes deny other practitioners’ 

charges because all of the providers were not listed by name for every level of care. 

-Fairbanks Hospital, Indianapolis, Ind. 

C. Pre-Existing Condition Exclusions: 

Some of our patients have participated in treatment prior to admission to our program and 

are considered as having a pre-existing condition. Some insurance companies refuse to cover 

services for this pre-existing condition. This makes it difficult to provide services for patients 

experiencing substance use disorders, which are often chronic, relapsing conditions. 

-Connections Counseling, Madison, Wis. 

The standard definition for “pre-existing condition” is “Any condition for which a person has 

sought medical treatment or advice within the past 12 months or any symptomology for which 

an ordinarily prudent person would have sought medical treatment or advice within the past 

six months.” By definition, a substance abuse patient must have had a history of symptoms or 

they would not have been approved for treatment by anyone’s standards. ... In addition, there 

would always be a question of whether a substance dependent person could ever be defined as 

a person with “ordinary prudence.” 

-Fairbanks Hospital, Indianapolis, Ind. 

D. Court-Ordered Treatment Exclusions: 

Most policies will not cover court-ordered treatment even though [the patients] meet criteria 

for alcohol dependence as stated in the Diagnostic and Statistical Manual-IV-TR. Some will 

not cover even before [the patient] is convicted for anything. One company sent out a 

questionnaire asking me questions about [the patient’s] Operating While Intoxicated history 

and any history resulted in denial. 

-Parkview Counseling Associates, LLC, Greenfield, Wis. 

[The court-ordered exclusion] clearly violates the intent and plain language of the federal 

parity statutes and should be expressly addressed. ... The insurance industry would be hardpressed to identify illnesses/medical treatment ordered by the courts other than treatment of 

mental health and substance use. 

-Rosecrance, Inc., Rockford, Ill. 

Most payors will not pay for court-ordered treatment for substance abuse. For medical 

conditions (since they are not generally judicially-related), many contracts will only state that 

there will not be coverage if the [injuries] are incurred as the result of committing a felony. In 

the environment of substance abuse, a patient will far more often be affiliated with the 

judicial system, but much court-ordered treatment is in lieu of pressing charges ... This 

creates a clear parity problem for psychiatric conditions such as substance abuse versus 

medical conditions. 

-Fairbanks Hospital, Indianapolis, Ind. 
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NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

E. Alcohol and Drug Trauma Exclusions: 

In September 2006, the American College of Surgeons adopted a formal statement calling for 

the repeal of this trauma exclusion. ... These insurance exclusion laws certainly violate the 

spirit of the parity statute and serve as barriers for early screening and prevention of 

substance use, abuse and dependency. In 2007, Illinois, Indiana, Oregon and the District of 

Columbia all repealed that law. 

- Rosecrance, Inc., Rockford, Ill.

F. Requirement to Complete Treatment: 

Treatment will often not be covered ... if the patient does not complete a portion or all of the 

treatment suggested in the final treatment plan, which includes aftercare. 

-Fairbanks Hospital, Indianapolis, Ind. 

-Insurance companies limit services through “clauses/exclusions,” for example [that the 

patient] must complete the entire phase of treatment. 

-Sundown M Ranch, Selah, Wa. 

2. Terms and Definitions 

N/A 

3. Medical Necessity 

Each company has its own language, and you have to say exactly what they want to hear or 

they will deny coverage. 

- Heartview, Bismark, N.D. 

The majority of managed care organizations do not want members to do higher levels of care 

if they have not failed at lower levels of care. For example, they may not authorize an 

intensive outpatient program if the member has not done outpatient treatment prior. They also 

may not authorize an intensive outpatient program and failed at that level. ... If someone is ill 

enough to meet the criteria for a higher level of care, why do they need to go to a lower level 

of care first and fail? It not only prolongs treatment which is expensive, but the member can 

become more ill, become harmed, and have a much harder time with a full recovery. 

-Ridgeview Institute, Smyrna, Ga. 

They do not inform us of what the criteria are for medical necessity. They will sometimes 

request our records to determine if our services meet their definition of medical necessity, but 

they don’t tell us their definition. 

-Connections Counseling, Madison, Wis. 

I had one plan make me call them one time per month to justify that my client still needed 

treatment. I would spend 45 minutes each time on the phone with the person who followed the 

case. I had to guess which symptoms would help to qualify him for continuing care. They 

insisted that if his wife did not attend Al-Anon [family support meetings] they would not pay 

for his treatment. 

- ChangePoint, Inc. – Vancouver Office, Vancouver, Wa. 
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NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

In the past, when consumers have been denied additional treatment “based on medical 

necessity,” I have been told I can refer back to the contract [online] for that information. In 

doing so, I have always been able to confirm that the consumer does meet the criteria, but this 

usually ends in an argument where the care manager of the insurance company wins! 

-Stepping Stones to Recovery, LLC, Augusta, Ga. 

Those individuals who present for treatment with cocaine dependence or amphetamine 

dependence are often kept out of inpatient detoxification services due to the fact that 

withdrawal from these drugs does not pose the physical risk associated with other drugs, 

including alcohol and opioids. However, recovery from cocaine or amphetamine dependence 

often requires the client to be removed from environments that may trigger overwhelming 

compulsions to use despite catastrophic consequences (as with other drugs). 

-Firebird Counseling, LLC, Akron, Ohio 

We see this scenario most often where the managed care organization makes a determination 

based on no formal participation in less intensive levels of care, even with evidence reflecting 

little or no stability in their environment, making it impossible to succeed. This has little or no 

impact on the plans' decision making. 

- Sundown M Ranch, Selah, Wa. 

Halfway houses, intervention services and educational programs are typically not covered by 

insurance plans. Insurance companies do not explain why certain services are not covered. 

-Gateway Rehabilitation Services, Moon Township, Pa. 

Some managed care companies do not cover someone if they have “opiate dependence.” This 

is extremely challenging, considering that this is a very serious addiction that appears to be 

on the rise. [Others] do not cover inpatient treatment for cocaine or marijuana. 

-Ridgeview Institute, Smyrna, Ga. 

4. Reasons for Denial 

There are so many reasons for not reimbursing, it’s mind-boggling. [An insurance plan] has 

denied reimbursement because they couldn’t read the clinician’s signature. They are made 

available to the agency after the fact. Then the agency has to “pay back.” 

-Ms. Neil A. Raffen, MEd, CAC II, CCS, Covington, Ga. 

Addiction patients may be denied because they have a support system, are motivated for 

treatment, are participating in [support] groups, attending [support group] meetings, etc.—

the managed care company may say the patient can be treated at a lower level of care. 

Addiction patients may also be denied if they are not motivated for treatment, are not

participating in group, are not attending meetings regularly, don’t have a sponsor yet, etc.—

the managed care company may say that the member is not motivated enough for treatment 

and they are not going to continue authorizing treatment. 

-Ridgeview Institute, Smyrna, Ga. 

This information is not made available to us as treatment providers, and from what my clients 

tell me the reasons that they are given are arbitrary and confusing. 

- ChangePoint, Inc. – Vancouver Office, Vancouver, Wa. 

They usually offer a myriad of reasons which do not even apply. When one unreasonable 

excuse is confronted and handled, they come up with ten others, trying to wear you down ... . 

Often the patient becomes fearful of having to pay for the expenses out of pocket after seeing 

denial after denial and drops out of treatment prematurely. 
Page 5 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

- Summerhill Counseling Center, Texarkana, Texas 

Most of the time, the insurance companies only authorize a certain number of days at a time. 

They tell us when to call back for authorization for additional days. Often they do not give us 

a response until late in the day of the last day authorized. If additional days are not 

authorized it causes a real hardship for the client and the program. Late in the day, the client 

has to try to make arrangements to leave. If the client doesn’t leave until the next day, the 

client has to pay for the previous day or the program doesn’t get paid for that day. 

-Eleventh Hour Rehabilitation Programs, Fresno, Ca. 

During the managed care process, the insurance company staff will say patients no longer 

meet their medical necessity criteria and/or that patients should be discharged to a lesser 

level of care. The medical necessity criteria are generally not [well] explained in a person’s 

insurance benefit coverage information book. 

-Hanley Center, West Palm Beach, Fl. 

5. Out-of-Network Coverage 

Approximately half of the time, our facility is included in plans’ out-of-network coverage. If 

we are not in the coverage, we will attempt to negotiate a “single-case agreement,” but this is 

usually not successful. The coverage difference between in-network and out-of-network is 

typically a significant amount of out-of-pocket expenses to the patient (i.e. 10 percent co-pay 

for in-network versus 50 percent co-pay for out-of-network. 

-Gateway Rehabilitation Center, Moon Township, Pa. 

In some cases, out-of-network has no benefits. In others, it doesn’t make sense for the insured 

[to receive out-of-network services]. In one recent case, I was filing claims to collect $5 for a 

session. 

-A New Direction Counseling & Training, Corpus Christi, Texas 

I had one insurance company refuse to put me on their panel because they already have six 

[providers] listed, however those six are not in the county or actively practicing therapy. 

When I explained this, they said they had providers in surrounding counties and consumers 

could travel there. When I explained traveling in the mountains and transportation were 

issues, they said they would make arrangements for the consumers to travel to providers in 

other counties. 

-Mid-Day Counseling, Sparta, N.C. 

If we treat someone who is out-of-network, we are for the most part out of any contact with 

the plan. We give the client receipts to submit, they do so and are not sure what they will be 

reimbursed or when they will be reimbursed. 

-ChangePoint, Inc. – Vancouver Office, Vancouver, Wa. 

We are included in some plans’ out-of-network coverage. The deductibles are usually much 

higher and out of the patient’s range to pay. Another problem we have recently encountered 

is that our program is the only intensive outpatient program in about a 150 mile radius. In 

this circumstance, under Texas law, the insurance companies are supposed to grant an “ad 

hoc” in-network status for the patients on a case-by-case basis. In the past they have done so. 

In the past two months, they are refusing to do so. 

-Summerhill Counseling Center, Texarkana, Texas 

The out-of-network benefits offered through some insurance plans do cover our programs, 

however some do not. Ultimately, coverage is based on whether or not Sundown M Ranch 
Page 6 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

falls into what the plan defines as an “approved inpatient facility or hospital.” These benefits 

are paid at a lesser rate than our daily rate. Most of the plans state that coinsurance is based 

on “reasonable and customary” charges. At the same time, they generally cannot provide 

what these reasonable and customary charges equate to. 

-Sundown M Ranch, Selah, Wa. 

Some companies will sign an ad hoc agreement and some will not. Some deny [out-of-network 

benefits] because we are not affiliated with a hospital, provide residential versus inpatient, or 

if there is another in-network facility in the area. We are in North Dakota, and “in the area” 

may mean over 100 miles away. 

-Heartview, Bismark, N.D. 

What we find to be most difficult is the limited nature of how many providers they will allow 

on a panel. It takes away choice from the client and we are often forced to refer them ... to 

lower quality treatment programs. 

-Valley Health Care System, Morgantown, W.V. 

In one incident, the plan recommended inpatient substance abuse services, but the plan did 

not have an in-network provider of this service. 

-Mr. David Edelman, LCSW, Fairfax County, Va. 

6. Additional Comments 

A. Reporting 

N/A 

B. Restrictions on Types of Providers: 

Some policies restrict provider licenses. We see that most often with the Certified Alcohol and 

Drug Counselor (CADC) [4,000 hours of experience and certification], but occasionally a 

policy is written where the outpatient providers must be a physician, psychiatrist or PhD, 

which then makes it impossible for most chemical dependency programs to provide affordable 

services. 

-Chestnut Health Systems, Bloomington, Ill. 

In the State of New Jersey, insurance plans have refused to allow Licensed Clinical Alcohol 

and Drug Counselors (LCADC) to be recognized as providers. They refuse to allow LCADCs 

to enroll as approved in-network providers, and they also refuse to allow LCADCs to be 

recognized as approved out-of-network providers, even though the N.J. statute authorizing 

licensure specifically includes a provision authorizing LCADCs as qualified healthcare 

professionals to receive third-party payments for services to clients within their scope of 

practice. 

-GoodPath, LLC, Hackettstown, N.J. 

Wisconsin’s version of a CADC III [requiring 7,000 hours of experience and certification] 

isn’t covered. Some say “Ph.D. or M.D. only,” some say “M.S.W. only.” There does not seem 

to be a requirement that they have any substance abuse experience. 

-Parkview Counseling Associates, LLC, Greenfield, Wis. 
Page 7 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

Some insurance companies require a mental health license for outpatient substance abuse 

treatment. Some deny residential coverage unless there is an attending physician and 24-hour 

nursing care on-site (which is more appropriately a requirements for acute care). 

- Johnson County Mental Health Center, Olathe, Kan. 

I dropped my Chemical Dependency license because most insurance plans will not pay unless 

the provider is a Licensed Professional Counselor, Licensed Master of Social Work or a 

psychologist. 

-New Direction Counseling & Training, Corpus Christi, Texas 

Once more, thank you for the opportunity to submit feedback in response to the 

MHPAEA RFI, and for the chance to share some input from providers and professionals 

in the field. 

For more information, please do not hesitate to contact NAADAC and NAATP’s 

Government Relations Department at 703.741.7686 x129. 

 
Page 8 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

List of respondents to NAADAC and NAATP’s 

“Parity Request for Information (RFI) Response Form” 

AdCare Hospital of Worcester, Inc.

107 Lincoln St. 

Worcester, MA 01605 

Contact: David W. Hillis, President 

AlChemy Counseling Services, LLC 

1903 Bragg Blvd # 2 

Fayetteville, NC 28303 

Contact: Joseph J. Youngblood 

A NEW DIRECTION Counseling & Training 

4455 South Padre Island Dr., Suite 105 

Corpus Christi, TX 78411 

Contact: Frederick M. Capps, Ph.D., LPC-S, 

ICAADC, QSAP 

BAC 

P.O. Box 1088 

Alamogordo, NM 88311 

Contact: Timothy W. Basha, BS, LADAC 

Carl D. Perkins Vocational Training Center, 

5659 Main St. 

Thelma, KY 41260 

Contact: James F. Recktenwald, CADC, MSW 

Cascadia-Bountiful Life Addiction Treatment, 

LLC. 

2817 Wheaton Way, Suite 205 

Bremerton, WA 98310 

Contact: Lindsay McGowan-Anderson 

ChangePoint, Inc., Vancouver Office 

10621 NE Coxley Dr., Ste 106 

Vancouver, WA 98662 

Contact: Karen A. Craig 

Chestnut Health Systems 

1003 Martin Luther King Dr. 

Bloomington, IL 61701 

Contact: Joan Hartman 

Columbia River Mental Health/Northstar Clinic 

6926 E. Fourth Plain Blvd 

Vancouver, WA 98661 

Contact: Patrick Dieter, CDP 

Connections Counseling 

1334 Applegate Rd, Ste. 101 

Madison, WI 53713 

Contact: Tami Bahr, LCSW, CSAC, ICS 

Counseling Associates, LLC 

115 5th Ave S., Ste. 301 

Lacrosse, WI 54601 

Contact: Mary Turner 

Counseling Services of Southern Utah, LLC 

561 E. Tabernacle 

St. George, UT 84770 

Contact: Leslie Talbot 

Ms. Sharon Cunningham, LAC, NCAC II 

Butte, MT 59701 

Devereux Texas Treatment Network 

1150 Devereux Dr. 

League City, TX 77573 

Contact: Robert L. Scott 

David Edelman, LCSW 

Falls Church, VA 22046 

Eleventh Hour Rehabilitation Programs 

5639 E. Park Circle Dr. 

Fresno, CA 93727 

Contact: Jessie Robb, LCSW, CADC I 

Fairbanks Hospital, Inc. 

8102 Clearvista Parkway 

Indianapolis, IN 46256 

Contact: Helene M. Cross 

Firebird Counseling, LLC 

2855 W. Market St, Ste. 2855 

Akron, OH 44333 

Contact: Valerie Kreider, PhD. 

Franklin Family Services 

332 Minnesota St., #E-1255 

St. Paul, MN 55101 

Contact: David Forsell 

Frona P. Israel, MSW, BBA, Inc. 

2225 N. University Dr. 

Pembrose Pines, FL 33024 

Contact: Frona Israel, LCSW 
Page 9 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

Gateway Rehabilitation Center 

311 Rouser Rd. 

Moon Township, PA 15108 

Contact: Martha Baldassare, Manager of 

Admissions Services 

GoodPath LLC 

38 Kim Lane 

Hackettstown, NJ 07840 

Contact: Harry Zerler, MA, LCADC, MAC 

Hanley Center 

933 45th St. 

West Palm Beach, FL 33407 

Contact: Dr. Barbara Krantz, CEO 

Heartview Foundation 

101 E. Broadway Ave 

Bismarck, ND 58501 

Contact: Kurt Snyder, Executive Director 

Mr. James Clarke, MA, LPC, MAC 

604 N. Main St. 

Adrian, MI 49221 

Johnson County Mental Health Center 

301 N. Monroe 

Olathe, KS 66061 

Contact: Barbara Burks 

Keystone 

1010 E. 2nd St 

Caniton, SD 57012 

Contact: Robert Bogue 

La Hacienda Treatment Center 

P.O. Box 1 

145 La Hacienda Way 

Hunt, TX 78024 

Contact: Art VanDivier, MA 

Lakeside-Milam Recovery Centers 

10322 NE 132nd St. 

Kirkland, WA 98034 

Contact: Amy Luehrs 

Linda B. Fuller, LCSW, P.A. 

800 North Fern Creek Ave, Ste. 2 

Orlando, FL 32802 

Contact: Barbara B. Fuller 

LUK, Inc. 

545 Westminster St. 

Fitchburg, MA 01420 

Contact: Gerald J. Manney 

Mid-day Counseling 

P.O. Box 205 

Sparta, NC 28675 

Contact: Sherry Cahn 

New Concepts & Associates 

1707 NE 74th Ter. 

Gladstone, MO 64118 

Contact: Dan R. Gray 

Oasis Behavioral Health Services LLC 

689 Central Ave. 

Barboursville, WV 25504 

Contact: William B. Webb, PhD, LICSW 

Olympic Pain & Addiction Services 

1334 Lawrence St. 

Port Townsend, WA 98368 

Contact: James K. Rotchford, MD, MPH 

Parkview Counseling Associates, LLC 

9910 W. Layton Ave 

Greenfield, WI, 53228 

Contact: Nancy A. Shirk 

Mr. Chet Phillipe, M.Div, CADCII Ret. 

Visalia, CA 93277-1739 

Ms. Neil A. Raffen, MEd, CAC II, CCS 

Covington, GA 30014 

Restoration Counseling 

78-150 Calle Tampico, Ste. 207 A 

La Quinta, CA 92253 

Mail: P.O. Box 536, La Quinta, CA 92247 

Contact: Patricia A. “Annie” McCoy, CADCA 

Rideview Institute 

3995 S. Cobb Dr. 

Smyrna, GA 30080 

Contact: Paul Hackman, President/CEO 

Rosecrance, Inc. 

1601 University Dr. 

 Rockford, IL 61107 

Contact: Renee Popovits and Janis Waddell 

Sacred Heart Medical Center 

17940 Farmington Rd., Ste. 140 

Livonia, MI 48152 

Contact: Jeffrey Berger, M.D. 
Page 10 of 10 

NAADAC-NAATP MHPAEA RFI Comments – Attachment A 

May 28, 2009 

Solution Focused Treatment Services 

2122 Rosefield Dr. 

Houston, TX 77080 

Contact: Michael Yeager 

Stepping Stones to Recovery, LLC 

2610 Commons Blvd. 

Augusta, GA 30909 

Contact: Jessica Epps, LMSW 

Summerhill Counseling Center 

4091 Summerhill Square 

Texarkana, TX 75503 

Contact: Jeanne Field Miller, MS, LPC, LMFT, 

LCDC, NCC, SAP, DABFE 

Sundown M Ranch 

P.O. Box 217 

Selah, WA 98942 

Contact: Scott Munson 

Therapeutic Alternatives, Inc. 

4024 Barrett Dr., Ste. 101 

Raleigh, NC 27609 

Contact: Steven P. Rochkind, MSW, PLCSW 

The Ringer Mental Health Center 

213 E. Bessemer Ave. 

Greensboro, NC 27401 

Contact: Stephen W. Ringer 

Valley HealthCare System 

301 Scott Ave 

Morgantown, WV 26508 

Contact: Gerard J. Schmidt 

Vet Center #710 

2990 Richmond Ave, Ste. 325 

Houston, TX 77006 

Contact: Dr. Edgar A. Wallace, LCSW, MAC, 

ICAADC