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From: John Madigan [mailto:jrnadigan@afsp.org] 

Sent: Friday, April 30, 2010 12:03 PM 

TO: f BSA, E-OHPSCA - EBSA 

Cc: Trevor Summefield 

Subjeck AFSP SPAN USA Comments on mental health parity rule 

To Whom It May Concern - 

Attached please find our comments. 

Please Let me know that you successfully received these comments. 

Thank you! 

lohn Madigan 

Senior Director of Public Policy 

American Foundation for Suicide PreventionlSPAN USA 

1010 Vermont Avenue NW Suite 408 

Washington, DC 20005 

202-4493600 ext. 103 

202-449-3601 (fax) 

jmadigan@afsp.org 

www.afsp.org 

www.spanusa.org 
>,-***.h. - .-*=*., h2 

r 

'8 -0. American Foundation ,..... /hr Suicide Prevention 

April 30,2010 

Internal Revenue Service 

Department of the Treasury 

Cmployee Benefits Security Administration 

Department of Labor 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Re: Interim Final Rules under the Paul Wellstone and Pete Dornenici Mental Health Parity and Addiction Equity Act of 

2008 (published in 75 Fed. Reg. 5410 et seq.] 

VIA EMAI L: E-OHPSCA.EBSA@dol= 

To The Departments: 

The American Foundation far Suicide Prevention (AFSPI and The Suicide Prevention Action Network (SPAN USA) 

appreciates the opportunity to comment on the interim final rules ("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. For many years AFSP and SPAN USA independently urged passage of federal legislation that would end heallh 

insurance benefits discrimination against people needing and seeking coverage for mental health and substance use 

disorder services. AFSP and SPAN USA merged on May 1,2009. Wlth passdge of MHPAEA our combined organizations 

believe that Congress has largely ended this discrimination in coverage for treatment of mental disorders, and we are 

particularly pleased that the IFR implements the law to its full extent. 

The American Foundation for Suicide Prevention (AFSP) is the leading national not-for-profit organization exclusively 

dedicated to understanding and preventing suicide through research, education and advocacy, and to reaching out to 

people with mental disorders and those impacted by suicide. 

To fully achieve its mission, AFSP engages in the fo!lowing Five Core Strategies: 

Funds scientific research 

Offers educational programs for professionals 

Educates the public about mood disorders and suicide prevention 

Promotes policies and legislation that impact suicide and prevention 

Provides programs and resources for survivors of suicide loss and people at risk, and involves them in the work 

of the Foundation 

SPAN USA, a divisiorl of AFSP 1010 Vermont Avenue, NW, Suite 408 Washington, DC 20005 

(202) 449-3600 phone (2021 449-3601 fax 
AFSPjSPAN USA 

MENTAL HEALTH PARrrV RULE COMMENTS, APRIL 30,2010 

PAGE TWO 

The Foundation's activities indude: 

Supporting research that is improving our understanding of suicide and its prevention. Since 20, AFSP has 

invested over $10 million in new studies, including research into treatments for people who are depressed and 

suicidal. 

r Providing education and information about depression and suiclde to professionals, the media and the public 

through workshops, trainings, the AFSP website, videos, publications, brochures and public service 

announcements. AFSP's PSA, "Suicide Shouldn't be a Secret," has reached 90 millian television viewers. 

Publicizing the rrlagnitude of the problems of depression and suicide, advocating for policies and legislation that 

can help prevent suicide and working to eliminate the stigma surrounding mental illness and suicide. 

Offering programs for survivors of suicide loss that can be of assistance and involving survivors in suicide 

prevention. AFSP sr~rvivor initiatives include the National Survivors of Suicide Day program, which was broadcast 

to over 175 communities and was simulcast on the AFSP website, the Survivor e-Network and trainings for 

survivor support group facilitators. 

Research shows that 90 percent of people who die by suicide have an underlying mental disorder at ttie lirnt. of their 

death. We believe that the final rule will for the most part provide the needed access to mental health and behavioral 

health services to reduce deaths by suicide. There are some areas we would like to address and believe that Centers for 

Medicare and Medicaid Services need to provide further clarification. 

The interim final rule provides some clarification of the MHPAEA language as it addresses scope of services. The text of 

MHPAEA defines mental health benefits and substance use benefits as that "benefits with respect to services." The 

language also states that: 

"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 cove rag^) and there are no separate treatment limitations that are applicable only with respect to mental health or 

substance use disorder benefits." 

Treatment limitations are defined as: 

"limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope Iemphasis 

added] or duration of tr~atment." 

Consequently, the interim final rule does address parity with regard to scope of services very broadly in determining that 

services offered across six classifications of benefits must be offered for mental health services if they are offered for 

medical/surgical services, Those classifications included: in-ne twork in pa tien t, out-of-network inpatient, in-network 

outpatient, out-of-network outpatient, emergency services and pharmacy. However, AFSP/SPAN USA is concerned that 

these protections would still allow for spparate and mnrc! restrictive limits on the scope of services provided with 

respect to mental health or substance use benefits as compared to medical/surgical benefits. 
AFSPISPAN USA 

MENTAL HEALTH PARITY RULE COMMENTS, APRIL 30,2010 

PAGE THREE 

To further reinforce the law's stated intention that limitations on services be no more restrictive for mental health or 

substance use benefits, we urge you to provide additional guidance as to categories of treatment services, where 

sewices for mental health or substance use also must be provided if medical/surgical benefits are provided within that 

category. These treatment categories should include: 

I) preventive services 

2) treatment services 

3) rehabilitation services. 

Treatment and rehabilitation services are commonly offered under mental health, substance use and medical/surgical 

benefits. While preventive benefits are often thought of in terms of physical health, examples of preventive mental 

health and substance use benefits include services such as substance abuse arid mental health screening, which can play 

an important role in improving health outcomes and reducing costs. These preventive services for mental health and 

substance use benefits should be placed an par with preventive services for medical/surgical benefits. 

Prevention is of particular importance. In a 2009 Report entitled Preventing Mental, Emotional, and Behavioral 

Disorders Among Young People: Progress and Possibilities the National Research Council and the Institute of Medicine 

(IOM) recommended that the federal government make preventing mental, emotional and behavioral disorders and 

promoting mental health in young people a national priority. Research from the National Institute of Mental Health has 

shown that 50 percent of all lifetime mental health disorders start by age 14. Yet, because the early signs of a disorder 

often are missed, the average diagnosis regularly occurs 10 years or more after the onset of symptoms. 

These late stage diagnoses indicate that we are regularly missing the two-to-four year window following the first onset 

of symptoms, which research has shown is most effective at reducing symptoms and preventing a full-blown mental 

disorder. If preventive services for mental health benefits, such a< annual depression screen in^ in adolescence, were 

offered at parity with medical/surgical benefits, identification of mental illness at its earliest stages would be greatly 

increased and the cost to the individual and society - an estimated $247 billion annually -would be greatly reduced. 

We urge the Departments to require health plans to cover preventive mental health and substance use services at the 

annual well-visit and to compensate providers for their time spent treating patients. 

Sincerely, 

Robert Gebbia 

Executive Director