Docket: CMS-2009-0040 

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

Comment On: CMS-2009-0040-0048 

Interim Final Rules under the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 

Document: CMS-2009-0040-DRAFT-0073 

NY 

Submitter Information 

Name: Laurie Flynn 

Address: 

New York, NY, 10019 

Organization: TeenScreen National Center for Mental Health Checkups at Columbia University 

General Comment 

See attached file(s) 

Attachments 

PUBLIC SUBMISSION 

As of: April 28, 2010 

Received: April 28, 2010 

Status: Draft 

Category: Other - Academic 

Tracking No. 80ae2a67 

Comments Due: May 03, 2010

Submission Type: Web

CMS-2009-0040-DRAFT-0073.1: NY

Page 1 of 1

file://C:\Documents and Settings\gelman.beth\Local Settings\Temporary Internet Files\OL... 4/28/2010
April 27, 2010 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

Attention: CMS – 4140 – IFC 

P.O. Box 8016 

Baltimore, MD 21244–1850 

To Whom It May Concern: 

As executive director of the TeenScreen National Center for Mental Health Checkups at 

Columbia University (National Center), I am submitting comments to the Centers for Medicare 

and Medicaid Services (CMS) with regard to the interim final rule [CMS-4140-IFC] on 

implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 (MHPAEA). I am writing to encourage the agency to more clearly define 

scope of services as it relates to preventive services, namely to ensure coverage of mental health 

screenings. The National Center firmly believes the intent of MHPAEA was to require insurance 

plans to cover the full scope of mental health services, including prevention services. We 

believe that this step is necessary to ensure mental health care is covered at the same level as 

medical and surgical care, and to protect individuals and families from added costs associated 

with needed mental health care. 

The National Center is a non-profit mental health initiative funded by a private family 

foundation. Our mission is to expand and improve early detection of mental illness by 

mainstreaming mental health checkups as a routine procedure in adolescent health care, schools, 

and other youth-serving settings. The goal of the National Center is to prevent adolescent 

suicide and reduce disability associated with mental illness. To achieve this goal, the National 

Center works to advance public policy and promote best practices to expand the availability and 

utilization of mental health checkups nationwide. The National Center provides voluntary 

mental health screenings in more than 900 sites in 43 states. 

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 “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 coverage) 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 [emphasis added] or duration of treatment.” 

Consequently, the interim final rule does address parity, albeit very broadly, with regard to scope 

of services 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 include: 1) in-network, inpatient; 2) out-of-network, inpatient; 3) in-network, 

outpatient; 4) out-of-network, outpatient; 5) emergency services; and 6) pharmacy. However, 

the National Center is concerned that these protections would still allow for separate and more 

restrictive limits on the scope of services provided with respect to mental health or substance use 

benefits as compared to medical/surgical benefits. 

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 services for mental health or substance use also must be 

provided if medical/surgical benefits are provided within that category. These treatment 

categories should include: 

1) preventive services; 

2) treatment services; and 

3) rehabilitative services. 

While treatment and rehabilitative services routinely are associated with mental health, substance 

use and medical/surgical benefits, preventive benefits are more commonly thought of in terms of 

physical health. However, examples of valuable and cost-effective preventive mental health and 

substance use benefits exist, including mental health screenings. In its April 2009 

recommendation, the U.S. Preventive Services Task Force’s (USPSTF) medical panel called on 

doctors in primary care settings to screen all adolescents age 12 to 18 annually for Major 

Depressive Disorder. This recommendation was based on peer-reviewed evidence that showed 

screening instruments developed for primary care accurately identify depression in adolescents. 

Further validating the importance and cost-effectiveness of mental health screening as a 

preventive service, the National Research Council and the Institute of Medicine (IOM) found in 

their 2009 report Preventing Mental, Emotional, and Behavioral Disorders Among Young 

People: Progress and Possibilities, screening in primary care settings offers the potential to 

intervene early and prevent fully developed mental health disorders. The IOM also notes a 

number of programs are effective and promote mental health and should be implemented more 

broadly. The IOM conclusions include: 

1) interventions before the disorder occurs offer the greatest opportunity to avoid the 

substantial costs to individuals, families and society that these disorders entail; and 

2) validated screening tools are available at little or no cost to primary care providers. 
Reinforcing the need to expand the interim final rule to include treatment categories, namely 

prevention services, are research findings from the National Institute of Mental Health that have 

shown 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 without widely used 

screenings, we are missing the two-to-four year window following the first onset of symptoms. 

Research has shown this to be the most effective time to intervene to reduce symptoms and 

prevent a full-blown mental disorder. If parity required preventive services for mental health 

benefits, such as annual depression screening in adolescence, to be offered on the same level as 

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

increased and the cost to the individual and society would be greatly reduced. The IOM 

estimates the costs of mental illness at $247 billion annually, and recent news reports of 

adolescent deaths by suicide in Palo Alto and elsewhere have highlighted the human toll in very 

real terms. 

Given the direct correlation between access to preventive services, such as mental health 

screenings, and the early identification of a mental illness, the National Center urges the 

Departments to expand the interim final rule to include treatment categories as a criterion to 

determine whether health insurance plans meet the required parity standard. This will ensure 

parity exists across all levels of care and will remove existing barriers that prevent individuals 

from access to needed mental health services. 

Sincerely, 

Laurie Flynn 

Executive Director 

TeenScreen National Center for Mental Health 

Checkups