May 3, 2010
Internal Revenue Service
PO Box 7604
Ben Franklin Station
Washington, DC 20044
Re: CC:PA:LPD:PR (REG-120692-09)
To Whom It May Concern:
On behalf of the American Academy of Actuaries’ Mental Health Parity Work Group, I am
submitting the following comments and requests for clarification in response to the request for
comments on the interim final rules under the Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008 (MHPAEA).
In addition to the comments and requests for clarification below, we would like to point out that
there are some significant timing issues. Many entities have already begun working on July 2010
and subsequent plan renewals, including benefit changes and revised rates, and will likely need
to complete such work before receiving further guidance and clarification from the Departments.
As such, retroactive changes will likely need to be made to comply with these regulations.
Question 1: The interim final rules do not allow comparing copays to coinsurance (and vice
versa) in the determination of whether a financial requirement meets the ‘substantially all’ and
‘predominant’ levels for medical/surgical benefits. In the outpatient in-network class, it is
common for health plans to use both copays and coinsurance for different service categories. In
some benefit designs, the majority of outpatient medical/surgical benefits are subject to either
coinsurance or copays, but neither the copay or coinsurance ‘type’ on its own will satisfy the
‘substantially all’ test. In the most extreme case, 65 percent of outpatient medical/surgical
benefits could be subject to coinsurance, 35 percent could be subject to copays, but a strict
application of the rules would conclude with neither copays nor coinsurance being applicable for
the behavioral health care benefits.
Can copays and coinsurance be combined in this testing using actuarially equivalent values? This
would include either the conversion of copays t