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Issue Brief: Parity

Section 1: The Policy Context for Mental Health and Substance Abuse Insurance Parity

Below is the national Mental Health America Policy Position and Call to action regarding mental health parity in health insurance.1 This position paper sets the context for policy work on parity. The key issues are:

  • Discrimination in health insurance coverage for mental health and substance abuse has existed despite the passage of other anti-discrimination legislation. Legislation is needed to reverse this arbitrary discrimination. Voluntary measures have not worked to end discrimination.
  • Mental health is essential to overall health.
  • Treatment works.
  • Studies have found that equalizing specialty behavioral health and general medical benefits will either not increase total healthcare expenses at all or will increase them by only a very modest amount of total healthcare premium The real cost lies in not treating behavioral health disorders.

The Metal Health America Policy Position and Call to Action was adopted in September 2006, before the passage of the Mental Health Parity and Addiction Equity Act in 2008. However, as will be outlined in this toolkit, there are still gaps in mental health and substance abuse parity and the principles of the policy statement are still relevant. On a practical note, there are citations in the policy paper that are that continue to be relevant and valuable in making the argument for full parity.

Mental Health America Policy Position and Call to Action

All people in America should have a right to health-care benefits, including needed behavioral health services. The Mental Health America calls on federal and state government to ensure, as a matter of law, that public and private health plans afford people access to needed behavioral health care and treatment on the same basis. Such services should be subject to the same terms and conditions as care and treatment for any other illness, without regard to diagnosis, severity, or cause.

All people in America should have a right to health-care benefits, including needed behavioral health services. The Mental Health America calls on federal and state government to ensure, as a matter of law, that public and private health plans afford people access to needed behavioral health care and treatment on the same basis. Such services should be subject to the same terms and conditions as care and treatment for any other illness, without regard to diagnosis, severity, or cause.


Background

Mental health is essential to leading a healthy life and to the development and realization of every person's full potential. Yet mental illness and substance-use disorders are leading causes of disability and premature mortality in the United States. As the President's New Freedom Commission on Mental Health observed in its final report2, mental disorders are "shockingly common." Most people are affected in some way by mental illness at some point in their lives.

With striking scientific advances over the last half century, behavioral health problems are now reliably diagnosed, and there is a range of treatments for virtually every such disorder. Those treatments have efficacy rates comparable to or exceeding those for many medical and surgical conditions. Yet all too often people with diagnosable mental disorders do not seek treatment. "Concerns about the cost of care - concerns made worse by the disparity in insurance coverage for mental disorders in contrast to other illnesses - are among the foremost reasons why people do not seek needed mental health care," the Surgeon General observed in the landmark 1999 report on mental health.3

Health insurance plans, from private individual and group coverage to the Medicare program, have long imposed barriers that limit access to needed behavioral health care for both mental and substance-use disorders, with far-reaching and often tragic results. No comparable barriers limit access to needed care for other illnesses. That such blatant discrimination continues to flourish -- more than a decade after enactment of the Americans with Disabilities Act, some forty years after the adoption of the first modern civil rights' laws, and nearly a century since this organization's establishment as a movement based on principles of social justice -- attests to the deep-rootedness of the stigma surrounding behavioral health disorders. But that such ongoing arbitrary discrimination is countenanced by federal law is nothing short of shameful.

The widespread practice of providing unequal coverage for behavioral health and other medical care not only limits access to needed care, but subjects many Americans to the risk of major financial losses from out-of-pocket costs. At the most profound level, these practices reinforce the poisonous stigma underlying disparate treatment of "others". That disparate coverage of behavioral health should be routine, and that discrimination against people with or at risk of behavioral health disorders should be lawful, is not only morally offensive in itself, but fosters a climate that tolerates and even encourages other forms of discrimination and weakens the fabric of equal-opportunity laws.

No rational basis supports these discriminatory health-insurance practices, which have drawn criticism from voices ranging from President George W. Bush to Fortune 500 chief executive officers.4 A landmark report by the National Business Group on Health recommends employers equalize their medical and behavioral benefit structures given evidence that parity yields significant clinical benefit without increasing overall healthcare costs.5

Lack of understanding regarding mental health and deep-rooted stigma help explain why it is still so common for health plans to place greater restrictions on treating behavioral health disorders than on other illnesses. While enlightened business leaders in some industries and communities have voluntarily provided parity protection for their workforces, voluntary measures are not an answer to the widespread discrimination facing most insured Americans. Thus, Mental Health America supports insurance-parity legislation.

Congress took a first step toward ending such discriminatory insurance practices when it enacted the Mental Health Parity Act of 1996. The Act established the principle that there should be no disparity in health insurance between mental-health and general medical benefits. By its terms, however, the Act provided only that employer health plans that cover more than fifty employees and that offer mental health benefits may not impose disparate annual or lifetime dollar limits on mental health care.

The 1996 Act represented an important milestone, but has not produced fundamental changes. People with or at risk of behavioral-health disorders still face widespread, arbitrary discrimination in insurance plans. As the General Accounting Office (GAO) reported in reviewing the Act's implementation, the vast majority of employers it surveyed complied with the 1996 law, but substituted new restrictions and limitations on mental health benefits, thereby evading the spirit of the law.6 As GAO documented, employers routinely limited mental health benefits more severely than medical and surgical coverage, most often by restricting the number of covered outpatient visits and hospital days, and by imposing far higher cost-sharing requirements.7

Although subsequent efforts to enact a comprehensive federal parity law have been unsuccessful, the federal Government further advanced the principle of parity by requiring insurers to equalize behavioral-health and other health benefits under the Federal Employee Health Benefits program (FEHB), which covers federal employees (including Members of Congress), retirees and dependents.8

Most states have adopted laws requiring parity between mental health and general health benefits in group health insurance. But those state laws vary widely in scope, and, under federal law, do not govern the health plans of the many employers who elect to self-insure.9

Those opposing parity legislation often assert that it will add to the cost of health care. But as the National Business Group on Health observed in its employer's guide to behavioral health services, a number of parity studies have found that equalizing specialty behavioral health and general medical benefits will either not increase total healthcare expenses at all or will increase them by only a very modest amount of total healthcare premium.10 The real cost lies in not treating behavioral health disorders. As the National Business Group noted, the indirect costs associated with mental illness and substance-use disorders - excess turnover, lost productivity, absenteeism and disability - commonly meet or exceed the direct treatment costs, and have been estimated to be as high as $105 billion annually.11

The discrimination in health insurance against people with or at risk of behavioral health disorders; the lack of real protection in current law against such discrimination; and the loss of life, health, and productivity attributable to these insurance barriers make it critical that Congress ensure that public and private health plans equalize medical and behavioral health benefit structures. Some attack parity legislation targeting employer-provided insurance as inappropriate regulation of benefits provided at the employer's discretion. But these discriminatory practices frustrate the compelling governmental interest of protecting all Americans equally, at whatever level of coverage the employer or the insured can afford. Indeed, federal law subsidizes employers through the federal tax code for providing health insurance to employees (allowing the cost of insurance as an ordinary business expense).12 It is wholly appropriate for Congress to condition entitlement to such tax benefits on employers' providing health benefits in a non-discriminatory manner.

Facing opposition to parity proposals, legislators have in some instances limited the scope of such measures and provided parity protection to only certain populations. Sound public policy aimed at achieving fairness is certainly not realized, however, when the law affords fair and equal treatment to some and not others. Mental Health America, therefore, does not support enactment of legislation that limits parity protection only to individuals who have specified diagnoses.13

Compelling principles dictate the adoption of comprehensive parity legislation. These include recognition that:

  1. All people in America should have a right to health-care benefits, including needed behavioral health services.
  2. Since comprehensive health-care is critical to people's well-being and to realizing their full potential, barriers to behavioral health care and treatment cannot be justified or tolerated.
  3. Coverage of needed health care - whether through government, employment, or individual purchase - must be afforded equitably to all people, without regard to the nature, severity, or cause of the individual's illness or disability.
  4. Insurance practices that set stricter limits on behavioral health coverage than on coverage for other illnesses cannot be justified and must not be permitted.

The Mental Health America Board of Directors approved this policy on September 8, 2006. It will remain in effect for five (5) years and is reviewed as required by the Mental Health America Prevention and Adults Mental Health Services Committee. Expiration: September 8, 2011

Section 2: More Context: Political History of Federal Mental Health and Addiction Insurance Parity

A September 2010 article by Colleen L. Barry, Haiden A. Huskamp and Howard H Goldman in Milbank Quarterly gives a summary of the political milestones in federal mental health and addiction insurance parity prior to the passage of the 2008 Mental Health Parity and Addiction Equity Law.14 Some historical highlights of parity policy:

  • In 1961, President Kennedy called on the U.S. Civil Service Commission to require the Federal Employees Health Benefits Program (FEHBP), the health insurer for federal employees, to cover psychiatric illnesses at a level equivalent to general medical care. However, by 1975, the FEHBP plans were allowed to scale back their mental health benefits. In 1981, the only federal employee option plan that provided parity-level psychiatric coverage was permitted to cut its coverage significantly.
  • In the 1970s and 1980s, efforts at promoting parity in private insurance were effective in some state legislatures.
  • In the early 1990s federal parity legislation was attempted in two significant initiatives but failed. In 1992 Senators Pete Domenici (R-NM) and John Danforth (R-MO) introduced the first federal mental health parity legislation. In 1993/1994 as part of President Clinton's failed efforts at health care reform, the plan contained a basic package that would have required some parity provisions and called for full integration of mental health services at parity with other medical services beginning in 2001. In 1995, Senator Domenici and Senator Paul Wellstone (D-MN) introduced a relatively comprehensive parity bill that failed.
  • In 1996, Senator Domenici introduced a scaled back bill requiring mental health parity only for annual and lifetime dollar limits. This Mental Health Parity Act of 1996 passed as an attachment to an appropriations bill. However, research indicates that health plans circumvented the law by tightening restrictions on other mental health benefits--on the number of hospital days and outpatient visits for mental health services.
  • In 1999, President Clinton directed the Office of Personnel Management to implement comprehensive MH/SA parity in FEHBP beginning in 2001 affecting 8.5 million insured lives. The 1999 directive covered all diagnoses listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and all aspects of in-network MH/SA benefits.
  • In 2003, under President George W. Bush, a recommendation for parity appeared in the final report of the president's New Freedom Commission on Mental Health-putting a Republican president on record as supporting parity.
  • By 2006, thirty-seven states had parity laws on their books. These laws vary substantially in the type of benefits covered, diagnoses included, population eligible, and direction regarding the use of managed care. Some state laws also are quite limited in scope. For example, South Carolina's law applies to public employees only. The more comprehensive state laws require equal cost sharing and prohibit the imposition of special inpatient day and outpatient visit limits. State laws also differ in the conditions covered, with some applying to only a subset of severe or "biologically based" disorders. Finally, only a handful of states cover treatment for substance use disorders. See Section 6 for a July 2008 summary of what states have done to ensure parity.
  • It is important to note that the Employee Retirement Income Security Act (ERISA) of 1974 limits the reach of all state parity laws by exempting from state insurance mandates those firms that self-insure. The Kaiser Family Foundation estimated that between 33 and 50 percent of U.S. employees were in self-insured plans in 2000 and thus, in accordance with ERISA, would not be covered by state parity laws. Using the Medical Expenditure Panel Survey Insurance Component (MEPS-IC), Buchmueller and colleagues (*2007) estimated that even though 45 percent of all insured private-sector employees lived in a state with a strong parity law, the ERISA exemption reduced by half the number of employees actually covered by state parity laws, thereby substantially limiting their reach.

In 2008, the Medicare Improvements for Patients and Providers Act was passed (effective January 1, 2010) eliminating Medicare's discriminatory copayments for mental and physical health.

In 2009, the Patient Protection and Affordable Care Act (health care reform) was passed. The Act is expected to expand health care coverage to an additional 32 million citizens and legal immigrants by 2019 through a combination of state-based private insurance exchanges and a Medicaid expansion. In addition, the new law includes a number of reforms to curb harmful insurance company practices as well as provisions to slow the growth of health care costs and improve quality of care.15 Some key parity provisions:

  • The Act calls for Establishment of state-based health plan "exchanges" by 2014 through which individuals and small businesses can purchase coverage with pooled risk and thus lower premiums. Mental health care and addiction treatment are included on the list of essential benefits that must be covered in new plans offered to the uninsured through the exchanges and to the newly eligible for Medicaid. The benefits will be defined by federal rulemaking. States can require benefits in addition to the essential benefits package be provided to enrollees.
  • Federal parity is expanded to The Mental Health Parity and Addiction Equity Act is expanded to apply to health insurance plans offered to small businesses and individuals and to newly eligible Medicaid recipients.

Section 3: Overview of the Mental Health Parity and Addiction Equity Law and Gaps in Federal Parity

In September 2010, a number of mental health advocacy organizations including Mental Health America released the Parity Toolkit for Addiction & Mental Health Consumers, Providers & Advocates, Parity Implementation Coalition, September 2010, First Edition.16 This excerpt from the September 2010 Toolkit gives a summary of the legislation.

Background on Parity

Most Americans with health insurance face greater barriers in accessing services for mental illness and addiction than they face for accessing care for other medical conditions. The majority of health plans impose higher out of pocket spending requirements and more restrictive treatment limitations on addiction and mental health benefits.

Today, with new technologies like MRIs and PET scans that allow scientists to look inside the brain, the evidence that mental illness and addiction are brain diseases is more compelling than ever before. Unfortunately, reimbursement policy has not kept up with science.

Since 1992, advocates like you have fought for health care equality for those with addiction and/or mental illness. A partial mental health parity law was passed in 1996 that was a significant step forward.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 to correct discriminatory health care practices against those both with a mental illness and/or addiction. Significantly, the law aims to curb both the financial and non-financial or "non-quantitative" ways that plans limit access to addiction and mental health care. Individuals with mental illness and/or addiction, their families, professionals in the field and employers worked together to pass the law.

In the end, turning a law into REAL lifesaving addiction and mental illness benefits means we have to fight for our new rights and benefits. This is OUR responsibility.

Brief Summary of the Parity Law

  • The parity law was signed into law on October 3, 2008.
  • The law went into effect for plan years beginning on or after October 3, 2009.
  • The law applies to self-insured and large employer group plans, but not to individual or small group plans.
  • The law does not mandate plans to provide mental health or addiction coverage, but when they are provided, they must be provided "on par" with medical benefits covered under the plan.

Here are ways the law requires addiction/mental health and medical benefits to be no more restrictive:

  • Lifetime or annual dollar limits imposed on mental health/addiction benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
  • Plans that provide Out-of-Network coverage under the medical/surgical benefit must provide on par Out-of-Network coverage under the addiction/mental health benefit.
  • Financial requirements (e.g., deductibles, co-payments, coinsurance, out-of-pocket expenses) imposed on mental health/addiction benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
  • Treatment limitations (e.g., frequency of treatment, number of visits, number of days, or similar limits on scope or duration of treatment) imposed on addiction/mental health benefits may NOT be more restrictive than those imposed on medical/surgical benefits.
  • There can be NO separate cost-sharing requirements or treatment limitations that are applicable only to mental health/addiction benefits.
  • Plans are prohibited from using "separate but equal deductibles." In other words, mental health/substance use disorder and medical/surgical benefits must add up together towards the same, combined deductible.
  • Criteria for medical necessity determinations and the reason for any denial must be made available to contracted providers or the plan participant or beneficiary upon request.
  • Where there is a state parity law or state mandate, the Federal Parity law serves as the floor and state laws must be enhanced to reach the federal floor.
  • State laws that require more than the federal law are NOT preempted.

Brief Summary of the Regulatory Process

Regulations are the written rules by which agencies implement law. Interim final regulations (IFR) implementing parity were issued February 2, 2010. The regulations give specific instructions for implementing the parity law.

Regulations are the written rules by which agencies implement law. Interim final regulations (IFR) implementing parity were issued February 2, 2010. The regulations give specific instructions for implementing the parity law.


"Interim final regulations" have the effect of binding law when they are issued. Parity regulators have said they will issue additional regulations, but we do not know when or if they will definitely come out. Until additional regulations are released, plans must comply with the existing regulations.

The regulations are effective for plan years beginning on or after July 1, 2010. Many plans start their plan year in January so the full effect of parity will not begin to be experienced in many markets until January 1, 2011.

6 classifications of benefits

The regulations define a 6-part classification scheme for benefits:

  • Inpatient, in-network
  • Inpatient, out-of-network
  • Outpatient, in-network
  • Outpatient, out-of-network
  • Emergency care
  • Prescription drugs

If a plan provides medical/surgical benefits in any or all of the above categories it must provide mental health/addiction benefits in the same categories.

Exemptions

  • Small employers who employ 50 people or fewer are exempt from the law (the new health care reform law expands parity to new small and individual plans with fewer than 50 people).
  • Local and state government plans may apply for an exemption from the Centers for Medicare and Medicaid Services. To see if your plan is exempt, go to: http://www.cms.gov/CCIIO/Resources/Files/hipaa_exemption_election_instructions_04072011.html
  • MHPAEA does not apply to Medicare plans.
  • MHPAEA does not apply to Federal Employees Health Benefits Plans (FEHBP) and TriCare/DOD plans.
  • Small employers who employ 50 people or fewer are exempt from the law (the new health care reform law expands parity to new small and individual plans with fewer than 50 people).

Cost exemption

  • Plans whose costs increase more than 2% in the first year and 1% in the following year may file for an exemption.
  • Plans that drop coverage because the plan meets cost exemption criteria must inform plan participants of a reduction in benefits.

Although the 2008 Mental Health Parity and Addiction Equity Act is a huge milestone in the fight for equal treatment of medical and mental illnesses, there are important provisions of the law and specific exemptions that call for continued advocacy at the state (and national) level.

Some important examples of gaps in coverage remaining after the passage of MHPAEA that are actionable by advocates are (as noted above):

  • Small employers who employ 50 people or fewer are exempt from the law (the new health care reform law expands parity to new small and individual plans with fewer than 50 people).
  • Local and state government plans may apply for an exemption from the Centers for Medicare and Medicaid Services. To see if your plan is exempt, go to: http://www.cms.gov/CCIIO/Resources/Files/hipaa_exemption_election_instructions_04072011.html
  • MHPAEA does not apply to Medicare plans. Note: in 2008 the Medicare Improvements for Patients and Providers Act was passed (effective January 1, 2010). One commenter notes (see item #3 in the annotated bibliography) that while Medicare's discriminatory copayments for mental and physical health care are being eliminated, much remains to be done to achieve true parity within Medicare. Medicare needs to recognize and pay for such critical mental health services as case management, psychiatric rehabilitation, and assertive community treatment. Medicare must cover payments for all behavioral health professionals. Also the 190-day lifetime limit on inpatient psychiatric hospital days under Medicare must be removed.
  • MHPAEA does not apply to Federal Employees Health Benefits Plans (FEHBP) and TriCare/DOD plans.
  • Plans whose costs increase more than 2% in the first year and 1% in the following year may file for an exemption.

Also note:

  1. There is no requirement in MHPAEA for employers to begin covering mental health and substance use disorders if they currently do not.
  2. There is no requirement in MHPAEA for employers to include any specific diagnoses-just what diagnoses they have chosen to cover before the federal law goes into effect.
  3. The Final Interim Rules did not specifically address the scope of services or continuum of care under federal parity-additional comments were invited.
  4. The Final Interim Rules do not give clarification to how employers can qualify for the cost exemption-the clarification was deferred until release of the Final Rules.

As noted above, the federal health care reform legislation greatly expands health insurance but does not erase the gaps in federal parity regulation. However, both the MHPAEA and federal health care reform legislation allow states to make stronger parity regulations. Therefore, real opportunity exists for advocacy at the state level to require every insured life to be covered by effective mental health and substance abuse services without regard to diagnosis, severity, or cause.

Section 5: What States Have Done to Ensure Insurance Parity

Many states have parity laws and regulations that go beyond federal parity even as it is outlined in the MHPAEA.

To see the Departments of Insurance in the five states with the best parity laws:

For insurance law links for every state see: http://www.americanamicable.com/Public/Useful_Links/State_Codes.htm

See also the January 2007 publication State Mandates for Treatment for Mental illness and Substance Use Disorders - http://store.samhsa.gov/product/SMA07-4228


Section 5: Strategies for Advocacy at the State Level

Two overarching advocacy challenges remain for state advocacy in the post 2008 passage of mental health parity:

  1. Ensure effective implementation of federal parity regulation. 
  2. Fill the gaps in mental health and substance abuse coverage with strong state laws to the extent possible.

Both of these challenges require education of consumers, family members, employers, purchasers, clinicians, policy makers, and the general public regarding the benefits of identifying and treating issues related to mental health and substance abuse.

While some states have regulations that go above and beyond the national parity law (see Section 6), some states have few or no parity regulations and therefore little experience in regulation in a parity milieu. For example, for state regulated plans, the state insurance commissioners have primary responsibility of enforcement of parity. Now they will be asked to enforce a federal statute, possibly without a state statute or regulation to support them. Therefore, there may be states that decide to pass a statute or develop regulations that allow them to more easily enforce the federal statute and regulations. However, if state insurance commissioners do not enforce the federal statute and regulations then the U.S. Department of Labor has secondary authority to enforce. In order to avoid confusion, all consumers and providers can call the department of Labor with a compliance issue and they will help to resolve the problem.

Advocacy efforts around state implementation of federal parity regulations should include:

  • Get to know insurance department regulators and ensure their familiarity with the federal statute.
  • Review processes in state insurance policy implementation to ensure consumers and advocates have meaningful input.
  • Assess the power of the state insurance department to enforce federal regulations both statutorily and with resources such as enough personnel and adequate training.
  • Advocate with state policy makers to address deficits.

Broader advocacy to improve mental health and substance abuse coverage includes tactics that advocates from a wide spectrum of interest groups use as well as some targeted strategies.

  • Successful legislative campaigns such as the national campaign for mental health parity include reaching out to and being willing to work with business and insurance plan groups as well as legislators whose interests are closely aligned with these groups. Bipartisan support is a necessity in most states.
  • Consider accepting incremental improvements to the requirements of federal parity. One important victory in the MHPAEA is establishing the federal law as the floor rather than the ceiling. So, state victories large and small now build on a much stronger legal/regulatory foundation than in the past. Remember that seemingly small steps like getting resources to appropriate regulators to implement the law is a significant victory in tight budget times.
  • Get the facts and use them. Know the most current literature on the costs (and costs savings) to employers for mental health parity. Similarly, know the most current literature on the economic (and human) costs of no or inadequate mental health and substance abuse treatment. The annotated bibliography in this report is a detailed resource.
  • Know individual legislators with a personal connection to mental health and substance abuse treatment and encourage them to use their personal stories to promote improvements to parity legislation.
  • Know the process. Become very familiar with the state's legislative process and the crucial points in the path of legislation and successful ways to cross those steps in the path. Friendly legislators' staff members can help.
  • Recruit constituents, especially constituents in areas of crucial legislators, to tell their stories. Particularly emphasize business and insurance plan leaders who believe in parity and can make the economic argument in favor of it. Successful individuals with serious mental illness-success made possible by effective treatment. Individuals adversely affected by a lack of parity can powerfully personalize the legislative fight for parity.
  • Be sure that state agencies that are impacted by parity are supportive. State agencies constantly provide information to legislators including estimating costs of providing certain services. State agency leaders who are uneducated or opposed to certain legislation can do much to discourage its passage.
  • Develop standardized materials and use them broadly. Use the same cost/benefit estimates in all arguments. Be sure all testimony is on message and emphasizes a few key points.
  • Know the opposition. Seek the key arguments of opposition leaders and develop materials to refute their arguments if possible. It is also important to acknowledge true differences and just make a forceful argument to support improved parity despite legitimate issues raised by opposition groups.
  • Develop a comprehensive media strategy and implement it in as many media outlets as possible.
  • Build a coalition of support broader than mental health advocates. For example, include health care providers/organizations, faith-based organizations, chronic disease/disability groups, homeless groups, hospital associations, law enforcement, think tanks, counties, unions, etc.

Section 6: Conclusion

In many ways states have led the way to mental health insurance parity with legislation that expanded coverage for certain diagnoses and certain categories of insured lives. With the 2008 and 2009 MHPAEA, Medicare parity improvements, and federal health care reform; the federal government has greatly expanded the federal role in promoting mental health parity. States with parity regulations provided important data to undergird arguments for federal parity. It is incumbent upon state advocates to push the envelope even further until every individual has access to high-quality mental health and substance abuse prevention and treatment services.

 

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