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

(202) 449‐3600 phone • (202) 449‐3601 fax

April 30, 2010

Internal Revenue Service

Department of the Treasury

Employee 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 Domenici Mental Health Parity and Addiction Equity Act of

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

VIA EMAIL: E‐OHPSCA.EBSA@dol.gov

To The Departments:

The American Foundation for Suicide Prevention (AFSP) 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 health

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. With passage 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 following 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
AFSP/SPAN USA

MENTAL HEALTH PARITY RULE COMMENTS, APRIL 30, 2010

PAGE TWO

The Foundation's activities include:

 Supporting research that is improving our understanding of suicide and its prevention. Since 2000, AFSP has

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

suicidal.

 Providing education and information about depression and suicide 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 million television viewers.

 Publicizing the magnitude 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 survivor 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 the time 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 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 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‐network inpatient, 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 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.
AFSP/SPAN 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

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  

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 and 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 on 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 as annual depression screening 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