The interim final rule provides guidance on implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act. It goes into effect on April 5th and applies to group health plans with 50 or more enrollees starting on or after July 1st. The rule divides benefits into six classifications and requires parity within each classification for mental health and substance use disorder benefits compared to medical/surgical benefits. It prohibits certain non-quantitative treatment limits for mental health/substance use disorders unless similar restrictions exist for medical/surgical benefits. The rule also prohibits separate deductibles, copayments, or out-of-pocket limits for mental health/substance use disorders and medical/s

1. Top-Line Summary of the Interim Final Rule on
Implementing the Wellstone-Domenci Parity Law
Feb. 2, 2010
On January 29, 2010, the Departments of Health and Human Services, Education, and Labor released
an interim final rule (IFR) providing guidance on how the Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act must be implemented. The IFR is available online at
http://www.federalregister.gov/OFRupload/OFRData/2010-02167_PI.pdf
Following is a brief summary of the provisions of major interest to mental health and substance use
disorder providers. The National Council will issue a more detailed summary in the next two weeks.
Effective Date: This IFR goes into effect on Apr. 5 and applies to insurance plans with plan years
starting on July 1 or later.
Plans that Must Comply with the IFR: The IFR applies to group insurance plans of more than 50
people. Although the Wellstone-Domenici law also applies to Medicaid managed care plans, these
plans are NOT included in the IFR. Additional guidance on how parity will apply to Medicaid
managed care will be released by the Department of Health and Human Services in the future.
Scope of Service: The IFR divides benefits into six classifications:
1. Inpatient, in-network
2. Inpatient, out-of-network
3. Outpatient, in-network
4. Outpatient, out-of-network
5. Emergency care
6. Prescription drugs
Within each classification, if a plan provides MH/SU benefits, those benefits must be provided at
parity with the medical/surgical benefits provided in that classification.
In addition, the Departments are encouraging public comments on whether and to what extent the
Parity Act addresses scope of services or continuum of care provided by insurance plans (information
about how to submit public comments is included in the IFR).
Medical Management: The IFR distinguishes between two types of limits on services: “quantitative
limits” (for example, limits on dollar amounts or number of sessions), and “non-quantitative limits.”
The IFR expressly prohibits plans from making use of the following non-quantitative limits, unless
similar restrictions exist for medical/surgical benefits: medical management, prescription formulary
design, “fail-first” or step therapies, and prior authorization.
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2. Cumulative Financial Requirements: The IFR prohibits plans from instituting separate deductibles,
copayments, and out-of-pocket limits for MH/SU and medical/surgical benefits. Any deductibles,
copayments, and out-of-pocket limits required by the plan must be integrated and cumulative for all
services.
Exemptions: The statute allows for health insurance plans to be granted a 1-year exemption from the
parity requirements if they experience total increased costs of 2% in the first year after implementation
and 1% in subsequent years. The criteria for this exemption are not included in this IFR. They will be
released in the future.
Comments: Public comments on the IFR will be accepted through May 3, 2010. Instructions for how
to comment are included in the official notice, to be published in the Federal Register on Tues, Feb. 2.
The National Council will be working with the Parity Implementation Coalition to create model
comments for our members to use as a resource. We encourage you to send us any comments that you
have. Please email Chuck Ingoglia (chucki@thenationalcouncil.org).
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