The Mental Health Parity and Addiction Equity Act (MHPAEA) generally prevents most group health plans and health insurance issuers that provide mental health and substance use disorder (MH/SUD) benefits from imposing more restrictive coverage limitations on those benefits than on medical/surgical (M/S) benefits. The law also requires plans and issuers to document comparative analyses of nonquantitative treatment limitations (NQTLs) (such as preauthorization requirements and network composition standards) that apply to MH/SUD benefits.
Final rules were released on September 9, 2024, by the Departments of Labor, Health and Human Services, and the Treasury (the Departments) that amend the existing rules and add new rules implementing MHPAEA.
For group health plans and group health insurance coverage, the final rules generally apply for plan years beginning on or after January 1, 2025. However, the provisions implementing the meaningful benefits standard, the prohibition on discriminatory factors and evidentiary standards, required use of outcomes data, and certain related comparative analysis requirements apply for plan years beginning on or after January 1, 2026. For individual health insurance coverage, the final rules apply for policy years beginning on or after January 1, 2026.
More information on MHPAEA and the text of the final rules is available at https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity and https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity.
Key Provisions
Under the final rules, plans and issuers must:
- Define whether a condition or disorder is an MH condition or SUD in a manner that is consistent with the most current version of the International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders.
- Offer meaningful benefits (including a core treatment) for each covered MH condition or SUD in every classification in which M/S benefits (a core treatment) are offered.
- Not use factors and evidentiary standards to design NQTLs that discriminate against MH conditions and SUDs.
- Collect and evaluate relevant outcomes data and take reasonable action, as necessary, to address material differences in access to MH/SUD benefits as compared to M/S benefits.
- Include specific elements in documented comparative analyses and make them available to the Departments, an applicable State authority, or individuals upon request.
Comparative analyses for plans subject to the Employee Retirement Income Security Act must also include a certification that they have engaged in a prudent process and monitored their service providers.
The new final rules also eliminate State and local government health plans' ability to opt out of compliance with MHPAEA.