For the first time in over 10 years, the Mental Health Parity and Addiction Equity Act (MHPAEA) has been updated, clarifying and strengthening regulations that were defined by the original 2013 legislation.
Enforcing payer compliance with the Act has been a significant pain point given the law's nonquantitative nature and at times ambiguous requirements. While the purpose of MHPAEA remains the same—to ensure health plan participants can access mental health and substance use disorder (MH/SUD) services with the same ease and coverage as their medical/surgical benefits—the new rules are expected to close loopholes, clarify expectations for payers, and ultimately improve access to care.
Key Changes
The final rule standardizes definitions and data evaluation requirements to improve compliance with MHPAEA. A few key updates are outlined below.
- Consistent Definitions: Definitions of MH conditions and SUDs are now solely based on the most current versions of the International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders.
- Nonquantitative Treatment Limitation (NQTL) Requirements: The nebulous nature of NQTLs gave payers wide latitude to impose prior authorization requirements and network adequacy standards that were inherently more restrictive than those placed on medical/surgical benefits. By further defining NQTLs and processes for measuring their impacts, MHPAEA makes it clear that the application of NQTLs cannot cause a material difference in access to MH/SUD services as compared to medical/surgical services.
- Data Evaluation and Transparency: Payers are now required to collect and evaluate data to identify and address material differences in access to MH/SUD benefits resulting from the application of NQTLs. Further, and perhaps most importantly, payers must now take reasonable action to address any differences that are found.
- Sunset of MHPAEA Opt-Out: The rule eliminates the ability of self-funded nonfederal government plans to opt out of compliance with MHPAEA.
Better definition of these requirements means all payers can be held accountable for assessing benefit parity in a standard manner—regardless of the specialty.
Greater Accountability, Expanded Access
A critical factor to eliminating disparities in coverage and access to treatment for MH/SUDs is ensuring that payers develop an adequate provider network. Under-resourced behavioral health provider networks create significant barriers to accessing services, ultimately worsening health outcomes. Boosting the size and quality of behavioral health networks will improve access to and utilization of behavioral health services.
The updated NQTL requirements are intended to hold payers accountable for growing their networks. Notably, the final rule acknowledges the prevalence of "ghost networks," citing a 2023 study finding that over 80% of mental health providers listed in payer directories were unreachable, not in-network, or not accepting new patients. The modified legislation should make it easier for individuals seeking MH and SUD care to receive it.
What's Next?
As of January 1, 2025, healthcare payers are now accountable for implementing the final rule, though they have until January 2026 to fully comply with the new standards.
Will the updates to MHPAEA spur payers to improve access to behavioral healthcare? Time will tell. For now, select commercial and Medicaid payer networks remain closed to new MH providers in certain specialties, and reimbursement rates remain severely depressed in certain US geographies. Already, the parity law is being challenged in court.
But the US Departments of Health and Human Services, Labor, and the Treasury have signaled their belief that mental health parity can benefit not just individual patients but also their families and communities. And with the changes to MHPAEA, it’s clear that they expect payers to be part of the solution.
