236 MASSACHUSETTS AVENUE, NE, SUITE 505, WASHINGTON, D.C. 20002 

May 28, 2009 

Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Attention: MHPAEA Comments 

Dear Sir or Madam: 

State Associations of Addiction Services (SAAS) and the Legal Action Center (LAC) appreciate the 

opportunity to submit comments to the Departments of Labor, Health and Human Services, and the 

Treasury on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 

2008 (MHPAEA). SAAS is the leading national organization that advocates on behalf of state 

associations of addiction prevention, treatment, and recovery providers, representing thousands of 

providers in 42 states around the country. The mission of SAAS is to ensure the availability and 

accessibility of quality drug and alcohol treatment, prevention, education, and research. The Legal 

Action Center is a non-profit law and policy organization that works to expand treatment and 

prevention services for people with alcohol and/or drug addictions, people living with HIV/AIDS, and 

people with criminal records. 

We were extremely pleased with the passage of the MHPAEA, and with it the elimination of barriers 

that have kept thousands of individuals with substance use disorders and mental illnesses from 

receiving critically important treatment services. We thank you for the opportunity to submit 

comments to help inform the rulemaking process going forward. Our comments focus on the need 

for future rules governing the MHPAEA to ensure that people who need substance use disorder 

treatment are better able to receive those lifesaving services. 

In developing rules to govern the MHPAEA, we urge the Departments to ensure that: 

1. Regulations governing implementation of the MHPAEA fully respect the preservation of State 

laws more favorable to the insured; 

2. Substance use disorder treatment benefits in group health plans are managed in a way that 

ensures that individuals are able to access the type and duration of treatment services that 

treatment professionals determine are clinically appropriate; 

3. The full continuum of substance use disorder treatment services is included in the definition of 

treatment services covered by the MHPAEA; 

4. Mechanisms to enforce the statutory and regulatory requirements of the MHPAEA are 

established; 

5. A comprehensive plan to inform and educate the public and beneficiaries about the 

requirements of the MHPAEA must be developed and implemented. 
1. The clear decision of Congress to protect State laws more favorable to the insured must be 

respected fully in the regulation process and regulations governing implementation must 

reiterate that stronger State laws remain in effect.

Extensive legislative history, including Committee and floor statements by chief House and Senate 

sponsors, makes clear that the MHPAEA provides a “floor” of protections not a ceiling, and that 

stronger State laws remain in effect and are not preempted by the new federal law. Regulations 

governing implementation of the MHPAEA must reiterate that State laws which provide better 

coverage, rights, methods of access to treatment and consumer protections from the standpoint of the 

insured remain in effect. 

2. Substance use disorder treatment benefits in group health plans must be managed in a way 

that ensures that individuals are able to access the type and duration of treatment services 

that treatment professionals determine are clinically appropriate. 

The recently approved MHPAEA requires parity in substance use disorder and mental health treatment 

benefits by prohibiting group health plans from imposing annual/lifetime dollar limits, co-pays and 

deductibles, or day and visit limits unless similar limitations or requirements are imposed for other 

medical and surgical benefits. This new federal law will improve access to lifesaving substance use 

disorder and mental health treatment by limiting the discriminatory barriers that have kept thousands of 

Americans with substance use and mental health disorders from receiving the care they desperately 

need. 

According to the National Household Survey conducted by the Substance Abuse and Mental Health 

Services Administration, in 2007, 23.2 million people, or 9.6 percent of the population, were classified 

with substance dependence or abuse. However, only 2.4 million, or just over 10 percent of those who 

needed treatment, received it at a specialty facility. Therefore, there were 20.8 million people, or 8.4 

percent of the population, who needed treatment for an illicit drug or alcohol use problem but did not 

receive it. Over 40 percent of those who tried to get help for their addiction were denied treatment 

because of cost or insurance barriers. 

Substance use disorders, like other chronic diseases, frequently require multiple episodes of treatment 

of varying intensity and duration. Remaining in treatment for an adequate period of time is critical for 

treatment success, as recovery can be a long process. In addition, no single form of substance use 

disorder treatment is effective for all individuals. Individuals should have choices about their 

substance use disorder care, just as they do for other areas of their health, that foster recovery and 

wellness through individualized community-based services and supports. Services that assist 

individuals with substance use disorders in their recovery and that improve their functioning should be 

available to all in need. To help individuals enter into and sustain their long-term recovery, regulations 

governing the MHPAEA should ensure that the full continuum of quality substance use disorder 

treatment is accessible to individuals and their family members. 

Prohibiting Additional Treatment Limitations. Under the MHPAEA, group health plans cannot limit 

the number of substance use disorder treatment episodes or visits or annual limits if those same 

restrictions are not imposed for treatment of other health conditions. The law makes clear that these 

requirements apply both to in- and out-of-network benefits, where group plans offer out-of-network 

benefits for medical/surgical benefits and cover substance use disorder treatment services. Rules 

governing the MHPAEA should clearly reinforce those requirements of the MHPAEA. In addition, 
regulations governing the MHPAEA should state that determinations about who needs what services, 

levels of care, and lengths of stay should be made by qualified treatment professionals, and where 

medical management is in use, tools including utilization review, criteria for review and approval of 

evidence-based treatment services, preferred provider networks and preauthorization should not be 

used to deny needed care as determined by a treating professional. 

Prohibiting Additional Financial Requirements. With the passage of MHPAEA, insurers are precluded 

from imposing additional financial requirements that are more restrictive than requirements for other 

health conditions. This provision applies to both in- and out-of-network benefits, where group plans 

offer out-of-network benefits for medical/surgical benefits and cover substance use disorder treatment 

services. Lifetime caps and annual limits for mental health and substance use disorder benefits are 

now equal to those for medical/surgical benefits. Rules governing the MHPAEA should clearly state 

that additional financial requirements not applied to benefits for other health conditions cannot be 

applied to substance use or mental health disorder treatment benefits. 

Requiring Additional Disclosure. The MHPAEA requires that insurers make medical necessity criteria 

and reasons for any denials of reimbursement available to participants and beneficiaries upon request. 

Regulations governing the MHPAEA should ensure that disclosure requirements are improved. Rules 

should make clear that limitations and restrictions on coverage under group health plans should be 

disclosed in a timely manner to group health plan sponsors and communicated in a timely manner to 

participants and beneficiaries under such plans in a form that is easily understandable. Rules should 

also clearly state that criteria and reasons for denial must be disclosed and subject to a meaningful, 

independent review process that accesses plan benefit utilization patterns and enables individuals to 

effectively challenge a denial. 

 

3. The full continuum of substance use disorder treatment services must be explicitly included 

in the definition of treatment services covered by the MHPAEA. 

The MHPAEA makes clear that, where mental health or substance use disorder treatment benefits are 

offered in group insurance plans, they must be offered at parity with benefits for other medical and 

surgical conditions. Individuals with substance use disorders should have access to the full array of 

services appropriate for recovery from these chronic health conditions. Recognizing that no one type of 

substance use disorder treatment is effective for all individuals, the scope of substance use disorder 

treatment services should be comprehensive. 

The rules governing MHPAEA should be clear that the full range of substance use disorder treatment 

services must be covered fully, equitably, and at parity with other health conditions in all group health 

insurance plans. Regulations on the MHPAEA should clearly state that the full continuum of quality 

substance use disorder treatment services are covered including assessment services, detoxification, 

residential care, therapeutic communities, half-way houses, hospitalization, outpatient treatment, 

medication-assisted treatment, case management, skills training and other rehabilitation services, 

recovery support services, primary medical services, family counseling, family unification, and 

continuing care.

 

4. Mechanisms to enforce the statutory and regulatory requirements of the MHPAEA must be 

established. 

In order for the MHPAEA to effectively eliminate discriminatory barriers to treatment for people with 

substance use and/or mental health disorders, enforcement mechanisms governing the new law must be 
established. Adherence to the MHPAEA statutory and regulatory requirements must be tracked. 

There must be clear, meaningful penalties for those who fail to comply with the statutory and 

regulatory requirements of the MHPAEA and these penalties should be imposed when insurers are 

non-compliant. 

5. A comprehensive plan to inform and educate the public and beneficiaries about the 

requirements of the MHPAEA should be developed and implemented. 

In order to successfully eliminate the historically discriminatory barriers that have prevented people 

with substance use and mental health disorder treatment needs from receiving critically important 

treatment services, consumers must be informed about the new requirements of the MHPAEA. The 

regulations governing the MHPAEA should include a discussion of the outreach effort needed to 

inform and educate consumers about the specific provisions and requirements of the new federal law 

and requirements for that plan’s implementation. 

We appreciate this opportunity to give comments on the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act of 2008. Please feel free to contact us if you have any 

questions or need additional information. Thank you for your careful consideration. 

Sincerely, 

Becky D. Vaughn 

Executive Director 

State Associations of Addiction Services 

(SAAS) 

 Gabrielle de la Guéronnière, JD 

Director for National Policy 

Legal Action Center (LAC)