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Children and Mental Health Parity

by Elijah Patton Wood

May 2005

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During the past decade, a growing awareness of the social and economic costs of mental illness has prompted state legislators to mandate increases in the coverage of mental illnesses by private health insurance companies.  These laws, commonly known as parity mandates, parity laws or simply "parity," require equal compensation for the treatment of both mental and physical illness.  This paper evaluates how institutional barriers – such as exemptions for small businesses, managed care organizations that act as gatekeepers for benefits, and federal restrictions on states’ powers to impose insurance mandates – may reduce the effectiveness of parity as a tool for ensuring coverage of mental health services for vulnerable populations. Parity is described by mental health advocacy groups – such as the National Alliance for the Mentally Ill (NAMI) and the National Mental Health Association (NMHA) – as a tool for improving coverage and reducing the stigma associated with mental illnesses.  However, a number of factors may greatly reduce the effectiveness of parity mandates.  These include managed care organizations that can act as gatekeepers to services; federal legislation that prohibits states from placing insurance mandates on self-funded health plans; and exemptions in both state and federal parity legislation for small employers that further limit the pool of people to whom parity is a relevant issue.  Unfortunately, insufficient data and restrictive definitions of mental illness in parity legislation continue to limit the ability of researchers to determine the extent to which parity increases coverage of mental health services for vulnerable populations.

Parity Defined

Parity encompasses a variety of legislative approaches to ensuring adequate insurance coverage for mental health illnesses.  Its definition often depends upon who is using the word.  NCSL defines a law as parity if it “ … requires an insurer to provide benefits for mental illnesses and/or substance abuse that are equal to those provided for other physical disorders and diseases.”¹  A parity provision that meets this strict definition might amend state insurance laws with a section that states, “Insurers shall provide benefits for “X” (“X” being mental illness and/or substance abuse), under the same terms and conditions as is provided for other illnesses and diseases.”²  The language of Vt. Stat. 8 V.S.A. §4089b (1997),the Vermont parity legislation implemented in 1997 that is widely hailed as the most comprehensive in the nation, states:

(b) A health insurance plan shall provide coverage for treatment of a mental health condition and shall not establish any rate, term or condition that places a greater financial burden on an insured for access to treatment for a mental health condition than for access to treatment for a physical health condition. Any deductible or out-of-pocket limits required under a health insurance plan shall be comprehensive for coverage of both mental health and physical health conditions.

(d) A health insurance plan shall be construed to be in compliance with this section if at least one choice for treatment of mental health conditions provided to the insured within the plan has rates, terms and conditions that place no greater financial burden on the insured than for access to treatment of physical conditions. The commissioner may disapprove any plan that the commissioner determines to be inconsistent with the purposes of this section.³ 

Other types of legislation that are sometimes referred to as parity include minimum mandated benefit laws and mandated offering laws.  Minimum mandated benefit laws typically specify base levels for mental health insurance coverage; benefits given under these provisions are not necessarily equal to those set for physical illnesses.  A typical minimum mandated benefit law states, “ … will require that benefits for “X” (“X” being mental illness and/or substance abuse), be provided at level “Y” (“Y” then specifies the degree top which “X” is covered.”⁴  The following language from Pa. Stat. tit. 40 §764g (2004), Pennsylvania’s minimum mandated benefit law, provides an example of minimum mandated benefit law:

(c) Health insurance policies covered under this section shall provide coverage for serious mental illnesses that meet, at a minimum, the following standards: 1) coverage for serious mental illnesses shall include at least thirty (30) inpatient and sixty (60) outpatient days annually; 2) a person covered under such policies shall be able to convert coverage of inpatient days to outpatient days on a one-for-two basis; 3) there shall be no difference in either the annual or lifetime dollar limits in coverage for serious mental illnesses and any other illnesses; 4) cost-sharing arrangements, including, but not limited to, deductibles and copayments for coverage of serious mental illnesses shall not prohibit access to care. The department shall set up a method to determine whether any cost-sharing arrangements violate this subsection.⁵ 

Mandated offering laws require insurers to either offer the option of mental health coverage to the insured, often with a higher premium, or mandate that, if an insurer decides to offer mental health benefits, they must be provided at a level specified by the law.⁶  Utah Code §31A-22-625 (2002), a Utah law, is an example of the first type of mandated offering legislation, specifying that:

At the time of purchase and renewal, an insurer shall offer to each small employer that it insures or seeks to insure a choice between catastrophic mental health coverage and 50/50 mental health coverage.⁷ 

Fla. Stat §627.6685 (2004), a Florida insurance mandate, is an example of the second type of mandated offering legislation, amending:

(a)1.  In the case of a group health plan, or health insurance coverage offered in connection with such a plan, which provides both medical and surgical benefits and mental health benefits: a.  If the plan or coverage does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate lifetime limit on mental health benefits. b.  If the plan or coverage includes an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage must: (I)  Apply that applicable lifetime limit both to the medical and surgical benefits to which it otherwise would apply and to mental health benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health benefits; or (II)  Not include any aggregate lifetime limit on mental health benefits which is less than that applicable lifetime limit.⁸ 

In this paper, the term insurance mandate describes any legislation that increases benefit levels or access to insurance benefits.  As figure 1 shows, many states have passed laws that closely adhere to one of these definitions, while others have blended aspects of two or more of the insurance mandate types by passing more than one law pertaining to mental health insurance coverage.

(Click on the figure to enlarge)

Talking Ethics: Parity and Values

Insurers and advocacy groups strongly disagree about the merits of parity.  At the heart of the debate is a dispute over what government should mandate.  Opponents believe that insurance mandates limit freedom of choice by imposing increased costs on businesses and individuals for services they may not want or be able to afford.  Proponents hold that parity in insurance coverage of mental illness helps fulfill an obligation to ensure social equity by increasing access to, and use of, health services. 

Mental health advocates explain that parity reduces the stigma and discrimination associated with mental illness that lead to inequitable differences in coverage.  NAMI, a prominent advocacy group representing consumers and families, states that “ … there is simply no scientific or medical justification for insurance coverage of mental illness treatment to be on different terms and conditions than other diseases.”⁹   The organization holds that mental health is a fundamental right and services that maintain it should be available to everyone.  Proponents also state that mental health is a crucial component of overall well-being because mental ailments often are associated with higher levels of physical illness.  Such groups cite data that shows that mental illness leads to higher expenditures by public and private health insurance providers through lost productivity due to absenteeism (missed work days) and elevated expenditures on visits to the doctor for treatment of physical illnesses related to mental ailments.^10,11 

Opponents of parity, including employer and insurer groups, focus on the importance of freedom and choice, describing insurance mandates as additional costs for businesses and consumers.  The nation’s largest business lobbying group, the U.S. Chamber of Commerce, states that insurance mandates, “ … artificially raise the cost of health plans, limit employers' ability to tailor benefits according to workforce need and demand, and stifle health plans' efforts to provide consumers with a variety of choices.”¹²   That is, the additional costs associated with mandates are passed along to consumers in the form of a decrease in insurance products on the market.  As a result, they say, consumer choice declines.  Opponents also assert that increased costs for employers and workers lead to decreased coverage: “When workers have to bear more of the cost of their group health coverage, they opt out of insurance programs – jeopardizing their overall health status.”¹³ 

Although both sides in this debate make cost-efficiency arguments to support their positions, the debate often is framed in terms of values.  At the heart of the issue is a disagreement about the relative importance of equity versus freedom of choice in health services.

Managed Care and Parity

Economic theory suggests that, in the absence of direct personal costs, people tend to overuse health services, which drives up system costs.  Parity increases access to services, which indicates that usage also will increase.¹⁴  Many insurers use managed care systems that attempt to rein in health spending by controlling access to and use of health services.  There is, however, some concern about the effectiveness of parity in a managed care environment: parity increases offerings, while managed care limits usage.  Parity legislation of all types seeks to increase coverage of mental health services in private insurance plans.  In contrast, managed care systems such as health maintenance organizations (HMOs) or managed care organizations (MCOs) use a variety of techniques to monitor and direct the use of health care services by members to contain costs, improve the quality of services, or both.¹⁵  Given the influence of managed care organizations in the field of mental health care, advocates have been concerned about the effect of managed care on access to mental health benefits.

Optimally, managed care services can improve the quality and appropriateness of the services that people receive: managed care plans that focus on preventive care can actually increase access to primary care, reducing the likelihood that a person will need more costly urgent care later in life.  A trend in managed care that may alleviate some advocates’ concerns is the use of carve-outs, which are healthcare payer systems wherein insurers form agreements with specialized contractors to administer and fund mental health services separately from physical health services.  Commonly stated reasons for using carve-outs include controlling system costs and improving service quality for targeted populations.  Some reviews of carve-out systems suggest that, at least in the private market, “ … costs have been contained, while access to any behavioral specialty care has tended to remain constant or even increase.”¹⁶  This suggests that carefully designed systems that couple parity and managed care may be able to control costs while targeting additional benefits to those in need.  The issue of system design remains  a major concern because constructing a network of providers to supply services in a carve-out can be difficult.  This may lead to limits on access to services despite official insurance coverage.

Parity Implementation

Studies examining the effects of parity on cost and access to services in managed care have found that spending generally does not increase.  Notably, the U.S. Department of Health and Human Services conducted an evaluation of Vermont’s 1997 parity law, which is among the most comprehensive parity law in the nation.  The resulting report, which gathered data from the first two to three years after parity was implemented in Vermont, concludes that, “ … increased use of managed care helped make parity affordable but may have reduced access and utilization for some services and beneficiaries.”¹⁷  The authors of the Vermont report explained that access to outpatient mental health services improved, while access to substance abuse services declined.  They also found that consumers’ share of total spending decreased and health plan spending, i.e., payments made by the insurance company, did not rise as much as critics of the plan feared: “Spending by Blue Cross Blue Shield of Vermont increased by four percent following implementation of parity. In other words, the amount spent increased by 19 cents per member per month.”¹⁸

Similar research by Mathematica Policy Research Inc., which examined the process of parity implementation in California in 1999, found that insurance premium costs did not appear to increase and employer health insurance offerings did not decline.  The main problems that they discovered were related more to difficulty in overcoming administrative hurdles during the transition than to the process itself.  The report states, “Early education and communication efforts about benefit and delivery system changes were not viewed as adequate by several stakeholders.”¹⁹ 

(Click on the figure to enlarge)

Parity: A Patchwork of Federal and State Legislation

Many states have used the primary federal parity legislation, the Mental Health Parity Act (MHPA), which was passed by Congress in 1996 with a yearly sunset, as a template for their insurance mandate laws, adding additional exemptions and inclusions in each new iteration.³⁰  As a result, parity is a patchwork of federal and state legislation, with all the complications that such a structure implies.

Table 1. Small Business Exemptions to Parity by Number of Employees State Small Business Exemption Cost Increase Exemption Alabama 50 employees or less None Alaska 5 employees or less None Arizona 50 employees or less 1% or more Arkansas 50 employees or less None Colorado 50 employees or less None Hawaii 25 employees or less None Illinois 50 employees or less None Indiana 50 employees or less None Kentucky 51 employees or less None Louisiana 50 employees or less 1% or more Maine 20 employees or less None Michigan None 3% or more Mississippi None 1% or more Nebraska 15 employees or less None Nevada 25 employees or less 2% or more Oklahoma 50 employees or less 2% or more Pennsylvania 50 employees or less None Tennessee 50 employees or less 1% or more Texas 50 employees or less None Virginia 25 employees or less None Washington 50 employees or less None West Virginia None State employees: 2%; 25 employees or less: 1%; 25 employees or more/HMOs: 2% Source: Andrew McKinley, Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse. Washington, DC: NCSL Healthy Policy Tracking Service, 2004

The Centers for Medicare and Medicaid Services suggests that the federal parity act “… may prevent your group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower – less favorable – than annual or lifetime dollar limits for medical and surgical benefits offered under the plan.”³¹  However, as they also take care to point out, “ … MHPA does NOT require group health plans and their health insurance issuers to include mental health coverage in their benefits package.”³²  In this respect, the MHPA conforms to the National Conference of State Legislature’s definition of a mandated offering because it compels insurers to offer equal coverage for mental illnesses in their insurance benefit packages if they offer mental health insurance coverage.  Insurers can, however, choose to not offer mental health insurance coverage or to offer an optional mental health benefit package with a higher premium.  Other specific provisions of the law include an exemption for small businesses with fewer than 50 employees, and an exemption for group insurers that can demonstrate a percent or greater cost increase in the cost of insurance due to the law.  Group insurers can be thought of as the bulk purchasers of health insurance policies; they are employers’ groups and associations such as unions that cannot efficiently self-insure but that can pool their purchasing power to buy discounted coverage from insurance companies.  As table 1 shows, many states include similar exemptions in their legislation, thus shielding small business and insurers from the risk of cost increases but also restricting the pool of people affected by state parity legislation.

(Click on the figure to enlarge)

A significant difference between federal and state insurance mandates is that the MHPA applies to the self-funded insurance plans that many large businesses maintain for their employees.  Whereas the Employee Retirement Income Security Act (ERISA) generally precludes states from passing laws regulating the self-funded health insurance plans that many large employers provide for their workers, the Mental Health Parity Act does apply to those plans.^33,34 Of the estimated 63 percent of firms that currently offer health insurance to their employees, approximately 54 percent have self-funded health insurance plans, “ … in which the employer assumes direct financial responsibility for the costs of enrollees’ medical claims.”^35,36 In other words, more than half of all private companies are not required to comply with state insurance mandates.  It is also important for state policymakers to consider the rate of self-funded plans by firm size.  As figure 3 shows, larger firms are more likely to self-insure than are smaller firms.  Together, the federal ERISA law and exemptions provided to employers by both state and federal governments such as exemptions for businesses with less than 50 employees limit the ability of parity legislation to ensure coverage of mental illnesses.³⁷ 

Conclusion

The degree to which parity laws that are designed to increase insurance coverage of mental illness are actually helping people is unclear for three reasons: 1) managed care organizations can act as gatekeepers, controlling access to benefits; 2) federal legislation prohibits states from placing insurance mandates on self-funded health plans, greatly reducing the number of people affected by any state insurance mandate; and 3) exemptions for small employers in state parity legislation further limit the pool of employees affected by this type of legislation.  Nevertheless, anecdotal evidence suggests that parity is helping some people by increasing coverage of selected mental illnesses under managed care arrangements such as carve-outs or those that place a strong focus on preventive care.  Insurance costs have increased little when parity is implemented, perhaps because managed care organizations act as gatekeepers for mental health services. 

For lawmakers who seek to understand this set of issues, better information about target populations would facilitate more effective policy.  State-level reviews of how current private, state and federal institutional structures interact to determine who has benefits, and at what levels, could further clarify best practices for the design of future policy.  Legislation drafted using this additional information could improve the ability of parity mandates to address the unmet needs of people with mental illness. 

Notes

1. Andrew McKinley, Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse (Washington, D.C.: NCSL Healthy Policy Tracking Service, 2004): 1-2.
2. Ibid., 1-2.
3. Vermont Statutes, “Vt. Stat. 8 V.S.A. §4089b,” http://198.187.128.12/vermont/lpext.dll/Infobase/511e/5799/633e/639c/651c?fn=document-, 2005.
4. Andrew McKinley, Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse: 1-2.
5. Pennsylvania State Code, “Pa. Stat. tit. 40 §764g,” 2004.
6. Andrew McKinley, Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse: 1-2.
7. Utah State Code , “Utah Code Ann. §31A-22-625,” http://www.le.state.ut.us/~code/TITLE31A/htm/31A16113.htm, 2002.
8. Florida Statutes, “Fla. Stat §627.6685,” http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0627/SEC6685.HTM&Title=->2004->Ch0627->Section%206685#0627.6685, 2004.
9. National Alliance for the Mentally Ill, “Mental Illness Insurance Parity,” Issue Spotlights (Arlington, Va., NAMI, January 2004), http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=13146.
10. Ibid.
11. Benjamin G. Druss, Robert A. Rosenheck, and William H. Sledge, “Health and Disability Costs of Depressive Illness in a Major U.S. Corporation,” American Journal of Psychiatry 157 (August 2000): 1274-1278.
12. U.S. Chamber of Commerce, “U.S. Chamber Calls New Health Care Mandates Bad Policy.” Press Release (Washington, D.C.: U.S. Chamber of Commerce) http://www.uschamber.com/press/releases/2002/april/02-84.htm, April 29, 2002.
13. U.S. Chamber of Commerce, “U.S. Chamber Urges Senate to Let Business Provide Mental Health Benefits Free of Mandates.” Press Release (Washington, D.C.: U.S. Chamber of Commerce) http://www.uschamber.com/press/releases/2000/may/00-72.htm, May 18, 2000.
14. Richard G. Frank, Chris Koyanangi, and Thomas G. McGuire, “The Politics and Economics of Mental Health ‘Parity’ Laws,” Health Affairs 16, no. 4 (July-August 1997): 110, 116.
15. Pam Pohly, “Pam Pholy’s Net Guide: Glossary of Terms in Managed Health Care,” http://www.pohly.com/terms.html, 1997.
16. Daniel P. Gitterman, Roland Sturm, and Richard M. Scheffler, “Toward Full Mental health Parity and Beyond,” Health Affairs 20, no. 4 (July-August 2001): 72.
17. M. Rosenbach, T. Lake, C. Young, et al., Effects of the Vermont Mental Health and Substance Abuse Parity Law, (Pub. No [SMA] 03-3822) (Rockville, Md.: U.S. DHHS, 2003), X.
18. Margo Rosenbach and Tim Lake, “Mental Health and Substance Abuse Parity in Vermont: What Did We Learn?” Issue Brief, No. 1 (September 2003), 2.
19. Timothy Lake, Alicia Sasser, Cheryl Young, and Brian Quinn “A Snapshot of the Implementation of California’s Mental Health Parity Law” (Cambridge, Mass: Mathematica Policy Research, Inc,.February 20, 2002), 23.
20. U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, Md.: U.S. DHHS, 1999), 124, 172.
21. Ibid., 180.
22. Gary Claxton, Isadora Gil, Ben Finder, and Erin Holve, 2004 Annual Employer Health Benefits Survey (Washington, D.C.: Henry J. Kaiser Foundation, 2004), 113.
23. Chris L. Jenkins, “Mental Illness Sends Many to Foster Care: Medical Costs Overwhelm Va. Parents,” Washington Post, November 29, 2004, Sec. B, p. 1.
24. Virginia State Executive Council for the Comprehensive Services Act, Report of the State Executive Council Workgroup On The Relinquishment of Custody for the Purpose of Accessing Behavioral Health Treatment (House Document No. 34) (Richmond, Va.: Commonwealth of Virginia, 2004).
25. Chris Koyanagi, Avoiding Cruel Choices: A Guide for Policymakers and Family Organizations on Medicaid's Role in Preventing Custody Relinquishment (Washington, D.C.: Bazelon Center for Mental Health Law November, 2002).
26. U.S. General Accountability Office, Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services (GAO/GAO-03-397) (Washington, D.C.: GAO, 2003), 14.
27. Mary Giliberti and Rhonda Schulzinger, Relinquishing Custody: The Tragic Result of Failure to Meet Children’s Mental Health Needs (Washington, D.C.: Bazelon Center for Mental Health Law March, 2000), 9.
28. Ibid., 8.
29. U.S. General Accountability Office, Child Welfare and Juvenile Justice, 2, 33.
30. Alan L. Otten, Mental Health Parity: What Can It Accomplish in a Market Dominated by Managed Care? (New York, N.Y.: Milbank Memorial Fund, June 1998), 1.
31. U.S. Center for Medicare and Medicaid Services, “The Mental Health Parity Act: Summary,” CMS, (Washington, D.C.: 2005), http://www.cms.hhs.gov/hipaa/hipaa1/content/mhpa.asp#summary.
32. Ibid.
33. U.S. General Accountability Office, Child Welfare and Juvenile Justice, 11.
34. National Alliance for the Mentally Ill, “The Mental Health Parity Act of 1996: Summary of the Law,” NAMI, (Arlington, Va.:  January 2004), http://www.nami.org/Content/ContentGroups/E-News/1996/The_Mental_Health_Parity_Act_of_1996.htm.
35. Gary Claxton, Isadora Gil, Ben Finder, and Erin Holve, 2004 Annual Employer Health Benefits Survey (Washington, D.C.: Henry J. Kaiser Foundation, 2004), 36.
36. Ibid., 123.
37. Andrew McKinley, Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse.

References

Claxton, Gary; Isadora Gil; Ben Finder; and Erin Holve. 2004 Annual Employer Health Benefits Survey. Washington, D.C.: Henry J. Kaiser Foundation, 2004.

Druss, Benjamin G.; Rosenheck, Robert A.; and William H. Sledge. “Health and Disability Costs of Depressive Illness in a Major U.S. Corporation.” American Journal of Psychiatry, 157 (August 2000).

Florida Statutes, “Fla. Stat §627.6685,” http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0627/SEC6685.HTM&Title=->2004->Ch0627->Section%206685#0627.6685, 2004.

Frank, Richard G.; Chris Koyanangi; and Thomas G. McGuire. “The Politics and Economics of Mental Health ‘Parity’ Laws.” Health Affairs, 16, no. 4 (July-August 1997).

Giliberti, Mary, and Rhonda Schulzinger. Relinquishing Custody: The Tragic Result of Failure to Meet Children’s Mental Health Needs. Washington, D.C.: Bazelon Center for Mental Health Law March, 2000.

Gitterman, Daniel P.; Roland Sturm; and Richard M. Scheffler. “Toward Full Mental health Parity and Beyond.” Health Affairs, 20, no. 4 (July-August 2001).

Koyanagi, Chris. Avoiding Cruel Choices: A Guide for Policymakers and Family Organizations on Medicaid's Role in Preventing Custody Relinquishment. Washington, D.C.: Bazelon Center for Mental Health Law November, 2002.

McKinley, Andrew. Behavioral Health: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse. Washington, D.C.: NCSL Healthy Policy Tracking Service 2004.

National Alliance for the Mentally Ill. “The Mental Health Parity Act of 1996: Summary of the Law.” Arlington, Va: NAMI; http://www.nami.org/Content/ContentGroups/E-News/1996/The_Mental_Health_Parity_Act_of_1996.htm.

National Alliance for the Mentally Ill. “Mental Illness Insurance Parity.” Issue Spotlights. Arlington, Va.: NAMI, January 2004; http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=13146.

National Center for Health Statistics. Health, United States, 2004: With Chartbook on Trends in the Health of Americans. CDC, Hyattsville, Md.: CDC, 2004.

Otten, Alan L. Mental Health Parity: What Can It Accomplish in a Market Dominated by Managed Care? New York, N.Y.: Milbank Memorial Fund, June 1998.

Pennsylvania State Code, “Pa. Stat. tit. 40 §764g,” 2004.

Pohly, Pam. “Pam Pholy’s Net Guide: Glossary of Terms in Managed Health Care,” http://www.pohly.com/terms.html, (1997).

Rosenbach, Margo, and Tim Lake. “Mental Health and Substance Abuse Parity in Vermont: What Did We Learn?” Issue Brief, 1 (September 2003): 2.

Rosenbach, M.; Lake, T.; Young, C.; et al. Effects of the Vermont Mental Health and Substance Abuse Parity Law. Rockville, Md: U.S. Department of Health and Human Services, Pub. No (SMA) 03-3822, (2003): X.

Shaffer, D., et al. “The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study.” Journal of the American Academy of Child and Adolescent Psychiatry 35 (1996a): 865–877.

U.S. Center for Medicare and Medicaid Services. “The Mental Health Parity Act: Summary.” Baltimore Md.: CMS, 2005; http://www.cms.hhs.gov/hipaa/hipaa1/content/mhpa.asp#summary.

U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General. Rockville, Md.: U.S. DHHS, 1999.

U.S. General Accountability Office. Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services (GAO/GAO-03-397). Washington, D.C.: GAO, 2003.

Utah State Code , “Utah Code Ann. §31A-22-625,” http://www.le.state.ut.us/~code/TITLE31A/htm/31A16113.htm, 2002  

Vermont Statutes, “Vt. Stat. 8 V.S.A. §4089b,”http://198.187.128.12/vermont/lpext.dll/Infobase/511e/5799/633e/639c/651c?fn=document-, 2005.

Virginia State Executive Council for the Comprehensive Services Act. Report of the State Executive Council Workgroup on the Relinquishment of Custody for the Purpose of Accessing Behavioral Health Treatment (House Document No. 34). Richmond, Va.: Commonwealth of Virginia, 2004; http://leg2.state.va.us/dls/h&sdocs.nsf/4d54200d7e28716385256ec1004f3130/1d60b4853f90143385256ee8006fc11c?OpenDocument.

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