These recommendations are intended to preserve the spirit and intent of the new legislation with
full consideration of the necessity to manage the costs of both medical and mental health care.
Mental health is essential to the health and well being of a// children and adolescents, and the
integration of mental health and physical health services is vital to improve the lives of millions
of Americans.

Sincerely,

kK Get ble Drow

Robert L. Hendren, D.O.
President


AMERICAN ACADEMY OF
CHILD. ADOLESCENT
ww PSYCHIATRY

Robert L. Hlendren, 0.0.

President-Elect May 28, 2009

Laurence L. Greenhill, WD.
Centers for Medicare & Medicaid Services

Mech Her vow WD Department of Health and Human Services
Attention: CMS—-4137-NC

Treasurer P.O. Box 8017

William Bernet, WD. Baltimore, MD 21244-8010.

(hair, Assembly
af Regional 0

To Whom It May Concern:

of Child andl Adolescent Psychiatry

Nat lh On behalf of the American Academy of Child and Adolescent Psychiatry
Past President (AACAP), Iam submitting comments to the Centers for Medicare and
Thomas F Anders, M.D. Medicaid Services (CMS) with regarding the public notice for comment
Tami D. Benton, M.D [CMS-4140-NC] on implementation of the Paul Wellstone and Pete

J. Miehael Houston, VD. Domenici Mental Health Parity and Addiction Equity Act of 2008

Paranyjit T. Joshi, M.D. (MHPAEA).

Christopher J. Kratochvil, WD.

Louis J. Kraus, MD. The AACAP is a medical membership association established by child and
Alice R. Mao, M.D. adolescent psychiatrists in 1953. Now over 8,000 members strong, the
ee Md. AACAP is the leading national medical association dedicated to treating
oth —_ Wo. and improving the quality of life for the estimated 7-12 million American
orothy & Stubbe, MLD youth under 18 years of age who are affected by emotional, behavioral,

developmental and mental disorders. AACAP’s members actively research,
Jerty Wiener Resident Member evaluate, diagnose, and treat psychiatric disorders and pride themselves on

Hane Le faleur giving direction to and responding quickly to new developments in
John E.Schowaller Resident Member addressing the health care needs of children and their families.
Glen P. Davis, WD.
sett Dor Despite living in the wealthiest nation in the world, many of our children in
Virginia Q. Anthony need of help lack access to appropriate mental health care. While almost
one in five children in the Unites States suffers from a diagnosable mental
Jowrva Editor disorder, only 20 to 25 percent of these children receive treatment. This is a
Andres Martin, MLD. i oo .
troubling fact considering treatment of many mental disorders has been
ANCAP News Editor deemed highly effective and, left untreated, mental illnesses are devastating
WanJung Kim, M.D. to our nation’s youth and their families. The MHPAEA was intended to
iran Commit a ensure equitable access and coverage of mental health services for all
Neal D. Ryan, Americans. With the appropriate regulations in place to implement the Act,
sana treatment will be available for many children and adolescents who need it.
Robert L. Stubblefield
Kala Pope a " The Institute of Medicine in their 2009 report, Preventing Mental,

Emotional, and Behavioral Disorders Among Young People: Progress and
3615 Wisconsin Avenue, NW Possibilities, recommended the federal government make preventing
Washington, DC 20016-3007
202.966.7300 800.333.7636
Fax 202.966.2891
Email: executive@aacap.org
http://www.aacap.org


mental, emotional and behavioral disorders and promoting mental health in young people a
national priority. While it is understood that insurers have a fiscal responsibility to manage care,
a concern exists that in anticipation of facing higher expenditures for reimbursement, insurers
and managed care organizations will look to limit other areas of care. Below are AACAP’s
responses and recommendations to your questions.

Financial Requirements and Treatment Limitations in Health Plans

AACAP is concerned about care being sacrificed in other areas, such as current medical benefits
to meet the parity requirements yet not increase costs. Plans sometimes limit treatment options
based solely on cost. These limitations are arbitrary and must be stopped. Evidence of efficacy,
not fear of anticipated cost, should determine available treatment options. At the same time, if a
level of care or prescribed treatment modality exists and is reimbursed for a physical illness, then
the analogous level of care or treatment modality utilized for the treatment of mental illnesses
must be provided as a covered benefit at the same level of reimbursement. In addition, some
mental health carve-outs have limited networks and apply stricter limits on providing care, and
these carve-outs should be required to adhere to any parity requirement to which the parent plan
is mandated.

With regards to equal copayment for mental and physical health treatment, AACAP recommends
closing any potential loop hole where mental health professionals are considered specialists in
providing the same services as a primary care provider. For example, a copayment for medical
management should be the same as it is for other medical management procedures done by a
primary care physician.

Additional Clarification of Provisions

It is unclear whether or not there are separate out of pocket deductibles for medical and mental
health. Separate but equal out of pocket maximums should be considered discriminatory toward
persons with mental illnesses and prohibited.

Medical Necessity Determinations

AACAP recommends an external group or body to standardize the definition of medical
necessity for MH/SA. At the least, health plans must follow professional organization

guidelines. All medical necessity information should be published in such a way that it is
available to providers or consumers and all appeals procedures should be clear. In medical
necessity determinations, physician reviewers must be a licensed physician of the same specialty,
working within the same state, and familiar with the resources available in the community. When
the health plan is unable to secure access to the appropriate level of care, it must authorize either
a higher level of care or services with an out of network provider. Network limitations, such as
day treatment programs or residential treatment centers that are too far away from the parents
home creates insurmountable barriers for the families.

Reasons for Denial

National accreditation organizations, such as URAC, provide a reasonable basis for the process
of communicating reasons for denial. Despite these national standards, physician providers
experience rigid and aggressive utilization review sometimes related to particular reviewers. This
can selectively limit access to mental health and substance abuse services. Reviews must be


done by physicians subject to the oversight of state physician licensing agencies, physicians
certified in the specialty area related to the treatment under review, and familiar with the service
network in the patient’s area. There needs to be prompt and accessible appeals that can be
initiated by the provider of services as well as by the patient.

Often, after attempts to catch the treating physician, the reviewer declines the request due to lack
of information. Reviewers must be required to make an appointment time (via phone) to discuss
the review with the treating physician. In any instance where a denial is given, the name,
discipline and phone number for the reviewer must be noted on the denial. Providing physicians
subject to unprofessional treatment by physician reviewers should be able to report this behavior
to state licensing agencies.

Some health plans use standards for utilization review that are established through broad
professional input and make them easily available to providers and patients. This should be
required of all health plans.

Scope of Out of Network Coverage

Historically, many insurance provider networks have insufficient numbers of child and
adolescent psychiatrists, hence there is a de facto discrimination when plan networks are not
maintained on the MH/SA side and provide “phantom networks” (names of providers not
participating). Insurers must maintain and demonstrate adequacy of mental health panel networks
on a quarterly basis. For panels that do not meet adequacy requirements based on size of covered
population and utilization data, the health plan must identify appropriate providers and services
as is currently done for medical panels. Panels must include an adequate number of providers
that are trained and licensed to treat children and adolescents. Panels should also be mandated to
include clinicians with appropriate cultural and linguistic ability based on the population served.
Training and credentialing of mental health providers must be equivalent to that for medical
providers. Specifically, self-report of specialization with mental health treatment or treatment of
children is not sufficient.

Inadequate networks leave plan participants without sufficient mental health treatment providers
and the need to go out of network not by choice. There is also little public information as to
when plan participants can seek out of network professionals as well as too much variability
between plans regarding coverage and reimbursement when plan participants seek care outside
of network. More information must be required to assist the plan participants.

Cost Exemption

As providers and advocates for consumers, we are concerned that the perceived increased cost
would leave the plans to respond by limiting access to specific services, such as home-based
wraparound services or residential treatment, or excluding vulnerable populations of children or
adolescents by with specific mental health diagnoses (e.g., autism, Attention-
Deficit/Hyperactivity Disorder). Practically, there are real concerns that these and other
strategies will be used to limit costs despite the fact that adequate safeguards already exist within
the new legislation to protect payers. Insurers should also be required to collect and publish
annual data on expenditures for the implementation of mental health parity with data subdivided
by level of care, facility type, service provided, diagnosis, and geographic area.

we