flfinitrd %tatw %rnatr WASHINGTON, DC 20510 December 21, 2012 President Barack Obama The White House 1600 Avenue NW Washington, DC 20500 Dear Mr. President: The passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was an historic step towards comprehensive access to mental health and substance use disorder services for insured Americans. In the four years since the passage of the law, many of us have signed onto letters to your administration or called members of your cabinet requesting timely and comprehensive implementation of the law. We think you agree that there has never been a more important time for all Americans to have access to the mental health and substance use disorder services that they need. Under the 2008 law, millions of Americans are entitled to access to a full range of mental health and substance use disorder services, but in the absence of a final rule, many people who need and have a right to these services may not have access to them. We urge you to act now to implement the law that will secure Americans' right to access the services they need. We are enclosing tln'ee previous letters that we have sent to your administration regarding the implementation of the law. These letters detail the specific concems that we have with the interim final rule released in 2010. Specifically, there are four issues that must be clarified in a final rule. First, the final rule must provide guidance as to whether plans must offer a comparable scope and range of medical and behavioral health services. Second, we believe plans must be required to disclose the criteria and policies they use to make benefit determinations on both medical and surgical conditions and behavioral health conditions. Third, the rule must provide greater clarity regarding quantitative and non-quantitative treatment limitations in order to allow for enforcement actions against inequitable treatment limitations, such as discriminatory prior authorization requirements. Finally, please provide guidance on the implementation of the law for Medicaid managed care plans. Our prior letters clarify congressional intent on these critical issues. Please act now to enforce this statute that was signed into law four years ago and ensure that Americans have access to the mental health and substance use disorder services that they need. Sincerely, Al Franken Tom Harkin United States Senator United States Senator Barbara Mikulski United States Senator hn Kerry United States Senator Robert Menen 2 Mark Be gich United States Senator Barbara Boxer United States Senator Debbie Stabenow United States Senator Gm aok Reed nited States Senator 1 Ron Wyden United States Senator tot/3 Sherrod Brown United States Senator Daniel Akaka United States Senator far' I Tester nited States Senator United States Senator Q3 Patrick Leahy Tom Udall United States Senator United States Senator Sheldon Whitehouse Patty tray United States Senator United States Senator Frank 13.. Laiitenberg Jeanne Shaheen United States Senator United States Senator Bernie Sanders United States Senator Richard Blumenthal Tim Johns?g/ United States Senator United Sta es Senator oseph I. Lieberman (Earl Levin United States Senator United States Senator cc: Secretary Sebelius, Secretary Solis, and Secretary Geithner 'ltlnitrrl ,%tatrs ,%rnatt WASHINGTON, DC 20510 May 12, 2011 The Honorable Hilda Solis The Honorable Kathleen Sebelius Secretary Secretary U.S. Department of Labor U.S. Department of Health and Human Services 200 Constitution Ave, NW 200 Independence Ave, SW Washington, DC 20210 Washington, DC 20201 The Honorable Timothy Geithner Secretary U.S. Department of the Treasury 1500 Ave, NW Washington, DC 20220 Dear Secretaries Solis, Sebelius, and Geithner: We are writing to follow up on our previous correspondence requesting additional guidance regarding the Paul Wellstone and Pete Dornenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). As the Interim Final Regulations went into effect for plan years beginning on or after July 1, 2010, we ask that this guidance be released before plans make decisions on 2012 benefit packages in May or June of this year. We are concerned that allowing the law to be implemented without specific guidance on scope of service, disclosure of medical criteria, and non-quantitative treatment limitations is resulting in insurance plans offering only limited behavioral health benefits in 2011. While MHPAEA was not intended to be a mandate for coverage of mental health or substance abuse services, once a plan has chosen to provide coverage for a specific mental health or substance use disorder, the law requires that behavioral a11d medical benefits be equivalent. With regard to scope of services, there are differing interpretations of the Interim Final Regulations. Its preamble states that no scope of services is conferred and solicits additional comments on this issue. The regulations themselves confer a scope of service by requiring that plans cover a minimum of six types of services. However, without clear guidance and clarification, health insurance plans are limiting the degree to which intermediate levels of behavioral health services are accessed. We also believe that plans should be required to disclose the criteria and policies they use to manage medical and surgical conditions and behavioral health conditions. This information is necessary to assess whether medical management or other forms of cost containment techniques are applied to behavioral health conditions in a manner that is comparable to and not more stringent than the medical management' applied to other medical conditions. Without access to both sets of criteria, regulators are unable to make the necessary comparison for effective enforcement of the law. While we thank the Department of Labor for releasing a 'Frequently Asked Questions' document on its website advising that plans must provide medical necessity criteria for both medical/surgical and mental health/addiction benefits. However, this guidance is non-binding and, to date, plans are still not complying. Final regulatory or sub-regulatory guidance is also needed to enable proper enforcement of the law regarding non<