The United States Departments of Health and Human Services (HHS), Labor, and the Treasury (collectively, the Departments) released new final rules implementing the Mental Health Parity and Addiction Equity Act (MHPAEA). The rules amend certain provisions of the existing MHPAEA regulations and add new regulations to set forth content requirements and timeframes for responding to requests for non-quantitative treatment limitations (NQTLs) comparative analyses required under the MHPAEA as amended by the 2021 Consolidated Appropriations Act.
The rules build on the government’s commitment to achieving the ultimate goal of the MHPAEA, which requires group health plans and health insurance companies that offer group and individual health insurance coverage with mental health or substance use disorder benefits cover those benefits in parity with medical and surgical benefits, without imposing greater restrictions on mental health or substance use disorder benefits when compared to medical and surgical benefits.
The new rules provide additional protections against more restrictive NQTLs for mental health and substance use disorder benefits when compared to medical or surgical benefits. NQTLs are requirements that limit the scope or duration of benefits, such as prior authorization requirements, step therapy and standards for provider admission to participate in a network. The rules also prohibit plans from using biased or non-objective information and sources that may have a negative impact on access to mental health or substance use disorder care when designing and applying a NQTL.
Specifically, under the final rules, a plan or issuer may not impose any NQTL with respect to mental health or substance use disorder benefits in any classification that is more restrictive, as written or in operation, than the predominant NQTL that applies to substantially all medical/surgical benefits in the same classification. For this purpose, a plan or issuer must satisfy two sets of requirements: (1) the design and application requirements and (2) the relevant data evaluation requirements.
The final rules also require plans and insurers to collect and evaluate data and take reasonable action to address material differences in access to mental health/substance use disorder benefits as compared to medical and surgical benefits that result from application of NQTLs, where the relevant data suggest that the NQTL contributes to material differences in access.
The final rules also amend the definition of “medical/surgical benefits,” “mental health benefits,” and “substance use disorder benefits” by removing a reference to state guidelines. Under the final rules, any condition, disorder, or procedure defined by the plan or coverage as being or as not being a mental health condition, substance use disorder, medical condition, or surgical procedure must be defined consistent with generally recognized independent standards of current medical practice. The definition of whether a condition or disorder is a mental condition or substance use disorder must follow the most current version of the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM). If generally recognized independent standards of current medical practice do not address how to treat a condition, disorder, or procedure, the rules state that plans and issuers may define it in accordance with applicable Federal and State law.
Most provisions of the final rules apply generally to group health plans and health insurance issuers that offer group health insurance coverage starting on the first day of the first plan year beginning on or after Jan. 1, 2025. However, the meaningful benefits standard, the prohibition on discriminatory factors and evidentiary standards, the relevant data evaluation requirements, and the related requirements in the provisions for comparative analyses apply on the first day of the first plan year beginning on or after January 1, 2026.
Statements
“Like medical care, mental health care is vital to the well-being of America’s workers,” said Acting Secretary of Labor Julie Su. “The final rules issued today make it easier for people living with mental health conditions and substance use disorders to get the life-saving care they often need.”
AHIP, the Association of Behavioral Health and Wellness (ABHW), the Blue Cross Blue Shield Association (BCBSA), and The ERISA Industry Committee (ERIC) released a statement regarding the final rule, expressing frustration at the changes. The statement reads, “The final Mental Health Parity and Addiction Equity Act (MHPAEA) rule will have severe unintended consequences that will raise costs and jeopardize patients’ access to safe, effective, and medically necessary mental health support. With nearly 50 million Americans experiencing a mental illness, there’s no question that addressing the shortage of mental health providers must be a top priority. There are proven solutions to increase access to mental health and substance use disorder care, including more effectively connecting patients to available providers, expanding telehealth resources and improving training for primary care providers. However, this rule promotes none of these solutions. Instead of expanding the workforce or meaningfully improving access to mental health support, the final rule will complicate compliance so much that it will be impossible to operationalize, resulting in worse patient outcomes.”