1025 Connecticut Avenue, NW, Suite 1012 • Washington, DC 20036-3536 • (202) 857-9735 phone • (202) 362-5145 fax • www.nacbh.org 

April 27, 2010 

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Hubert H. Humphrey Building, Room 445-G 

200 Independence Avenue, SW 

Washington, DC 20201 

Re: CMS-4140-IFC 

Dear Gentlepersons: 

The National Association for Children’s Behavioral Health (NACBH) appreciates the opportunity to 

comment on the interim final rules implementing the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act of 2008. As an organization representing multi-service treatment 

agencies for children and youth with emotional disturbances and their families, our members, and the 

children and families they serve, have a keen understanding of the full array of services children need 

during the course of treatment and the services that for too long have been denied. The implementation of 

parity for mental health and substance use disorders will begin a process to provide services based on 

need and clinical appropriateness rather than on arbitrary, capricious or fiscal determinations. Given the 

complexity of the regulations we would like to concentrate our comments on the several areas that most 

affect children and family services and respond to the Departments’ request for additional examples of 

nonquantitative treatment limitations (NQTL) within medical management or general plan design. 

Classification of Benefits: 

The regulation establishes six classifications of benefits in which parity must be applied, inpatient/innetwork, inpatient/out-of-network, outpatient/in-network, outpatient/out-of-network, emergency services 

and prescription drug coverage. We commend the Departments for recognizing Congress’ intent to 

assure that benefits be provided without consideration to treatment setting, but rather by benefit and 

service. 

It has long been recognized that children require an array of services based on individual needs and levels 

of service intensity. Optimally, services are organized based on levels of intensity which combine a 

number of variables including clinical services, support services, crisis stabilization, and supervision. The 

implementation of parity for mental health and substance use disorders based on broad classifications of 

services will allow services to be determined based on clinically accepted and appropriate levels of care. 

Furthermore, this will lead to the appropriate use of resources, both fiscal and clinical, ultimately assuring 

that care is clinically not cost driven. Therefore, we commend the Departments for recognizing and 

conferring a scope of service for mental health and substance use benefits comparable to and no more 

restrictive than medical surgical benefits, requiring that parity requirements for financial and treatment 

limitations be applied on a classification by classification basis. Again, these provisions will support 

access to a more comprehensive array of services essential to meeting the individual treatment goals of 

the child. 
Centers for Medicaid and Medicaid Services 

April 27, 2010 

CMS-4140-IFC 

page two 

The law and regulations also require that when a plan provides mental health or substance use benefits in 

any classification of benefits, it must provide them in all classifications of benefits in which 

medical/surgical benefits are provided. Furthermore, quantitative and nonquantitative treatment 

limitations cannot be applied more restrictively or stringently for mental health and substance use benefits 

than with respect to the medical/surgical benefits provided. Individual plans will have the responsibility 

of defining and designing types of services, financial requirements and treatment limitations for each 

classification. While this may prove cumbersome and complicated, the requirements that the benefits be 

defined under the terms of the plan, in accordance with applicable Federal and state law and be consistent 

with generally recognized independent standards of medical care, requires the full input and consultation 

with the array of appropriate clinicians and specialists needed to assure comparability in mental health 

benefits with those of medical/surgical benefits. While the regulation does not define “clinically 

appropriate standards of care” there exists sufficient guidance and practice in the development of Federal, 

state and private health benefits to assure that the “processes for developing evidentiary standards” are 

comparable and applied no more stringently to mental health and substance use benefits than to 

medical/surgical benefits. 

Nonquantitative treatment limitations: 

Recognizing that health insurance plans impose a variety of limits on the scope and duration of services 

we are most appreciative that these regulations prohibit the imposition of any nonquantitative treatment 

limitations to mental health and substance use disorder benefits which are determined by any methods or 

means not similarly used to determine limitations on medical/surgical benefits. This will require that 

health plans maintain sufficient panels of mental health providers for all authorizations of care, medical 

necessity determinations, concurrent and retroactive reviews. Where services for children are concerned 

it is especially critical that plans identify appropriate providers that are trained and licensed to treat 

children and adolescents. 

Similarly the range of mental health and substance use treatment providers must be adequate to meet the 

needs of the covered population, and should not be more restrictive than the range of medical/surgical 

health providers. For example, if physical health professionals are admitted to provider networks (or 

eligible for reimbursement under a plan that does not have a network) based upon state licensure in a field 

qualified to serve covered conditions, the requirements should be the same for mental health and 

substance abuse treatment providers. Any exclusion of entire licensing or practice categories on the 

mental health/substance abuse side should be made only if similarly determined exclusions are made on 

the physical health side. 

The range of mental health and substance abuse treatment settings must not be more limited, or limited 

based upon different criteria or methodology, than are medical/surgical treatment settings. Within a given 

classification, if medical/surgical patients are admitted to the most appropriate treatment setting or level 

of care based on medical necessity and generally recognized independent standards of practice for their 

condition, the same must be true for covered mental health and substance abuse disorders. 

The number of mental health and substance abuse treatment professionals and agencies currently 

accepting new patients from the plan should be sufficient to serve the beneficiary pool as promptly as 

medical/surgical services are delivered.
Centers for Medicaid and Medicaid Services 

April 27, 2010 

CMS-4140-IFC 

page three 

We appreciate that the list of the nonquantitative treatment limitations articulated in the regulations, while 

including many of the most inequitable limitations and restrictions on mental health and substance use 

disorders, is non-exhaustive. This encourages a full examination of “any processes, strategies, 

evidentiary standards, or other factors used in applying a NQTL to mental health or substance use 

disorder” that is not applied to a medical/surgical benefit. 

In closing we want to emphasize our support of the statutory language which defines parity as the “quality 

or state of being equal or equivalent.” While we understand that some ambiguities will arise as 

implementation proceeds, we believe Congressional intent was clear in its desire to end the long-standing 

discrimination between benefits for mental health and substance use disorders and medical/surgical 

benefits. 

Thank you. 

Sincerely, 

Joy Midman 

Executive Director