On September 9th, the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury released new final rules for mental health standards coverage that seek to strengthen implementation of the decades-old Mental Health Parity and Addiction Equity Act (MHPAEA). The rules require insurance plans to assess how their nonquantitative treatment limitations affect access to mental health and substance use disorder services compared to medical and surgical benefits. They apply to group health plans and group health insurance coverage starting January 2025 but some policies, such as the relevant data evaluation requirements and the related provisions for comparative analyses, will begin in 2026. The rule improves upon the previous requirements by refining its standards and increasing the rule’s scope, now requiring more than 200 additional health plans to comply with MHPAEA. AHPA will publish a full summary of the rule in our next article.

Below are key highlights from the rule:

  • Requires health plans to make comparative analyses to determine if they are providing inadequate access to mental health and substance use services. The outcomes of these evaluations will show plans where they are failing to meet the law’s requirements, and where they will need to make changes to come into compliance. For example, plans must review claims data to analyze claims denials, network utilization rates, and provider reimbursement rates for mental health and behavioral services compared to other medical services. More guidance on the data sets that plans must review will be released in the future.
  • Makes clear what plans cannot do. The rule states that plans cannot use more restrictive prior authorization, other medical management techniques, or narrower networks than those used for medical and surgical benefits.
  • Does not specify which mental health or behavioral services plans must offer. Instead, the rule requires plans to provide “meaningful benefits,” meaning at least one “core treatment” for each covered condition. For example, coverage of Applied Behavior Analysis therapy as a core treatment for autism, coverage of nutritional counseling as a core treatment for eating disorders, and coverage of medications to treat opioid use disorder as a core treatment for substance use disorder.

What to Expect?

While the rule is a welcomed step, the penalties for insurers and employers for non-compliance are not completely clear, creating potential challenges for implementation. Some plans have argued that complying with the rule would require significant financial investments like purchasing new data systems and hiring additional staff. These challenges could undermine MHAEA’s efficacy. Additionally, although plans are required to analyze data to ensure they are compliant with the federal mental health parity law, the rule doesn’t clearly define the term “material difference” when determining whether there are significant differences in accessing mental health and behavioral services compared to other medical services.

AHPA extends our gratitude to Nikita Leukhin, guest author of this article.
Nikita is a student in the Bachelor of Healthcare Management program at Kettering College.