Overview of 2025 MHPAEA Report to Congress

April 1, 2025

Dan Finnegan, Compliance Specialist, Benefits Compliance

On January 13, 2025, the Departments of Labor (“DOL”), Health and Human Services (“HHS”), and the Treasury (“IRS”) released their 2024 annual report to Congress regarding agency education and enforcement efforts related to the Mental Health Parity & Addiction Equity Act of 2009 (“MHPAEA”). Throughout 2024, the DOL’s Employee Benefit Security Administration (“EBSA”) reports that it issued the following enforcement actions as related to MHPAEA:

• 17 initial letters requesting comparative analyses of 22 NQTLs (19 unique NQTLs);
• 45 Insufficiency letters covering over 40 NQTLs; and,
• 13 initial determination letters finding that plans and issuers had violated MHPAEA requirements for 21 NQTLs (14 unique NQTLs)

During the CMS Reporting Period, CMS issued the following enforcement actions related to MHPAEA:

• 22 initial letters requesting comparative analyses for 22 NQTLs (12 distinct NQTLs);
• 10 insufficiency letters covering 10 NQTLs;
• 19 initial determination letters finding that plans and issuers had violated MHPAEA’s requirements for 19 NQTLs; and,
• 3 final determinations of noncompliance finding an issuer violated MHPAEA’s requirements for 3 NQTLs.

Employer Action Items

• Confirm preparation and delivery of the plan’s written comparative analysis. Verify each health plan option has conducted and memorialized a written comparative analysis of nonquantitative treatment limitations (“NQTLs”), and that a copy of the written comparative analysis is available for transmittal and review upon receiving a request from either of the DOL or CMS. 
• Review QTLs and NQTLs applied by the plan or issuer. Review each plan level option to ensure the plan does not impose more stringent benefit limitations upon mental health and substance use disorder (“MH/SUD”) benefits than those limitations applied to respect the plan’s medical and surgical (“M/S”) benefits coverage. 
• Examine network adequacy across the platform. Examine each plan’s network adequacy and network composition for purposes of assuring that plan participants have equal access to both M/S and MH/SUD providers and covered benefits. 
• Examine provider reimbursement methodologies across the platform. Confirm that any benefit limitations that are applied by the plan respective to plan-level provider reimbursements are applied in parity with, and applied no more stringently than, any such limitations applied respecting M/S benefits under the plan.  

Summary

MHPAEA is a federal law that prevents group health plans that provide MH/SUD benefits from imposing less favorable benefit limitations on those benefits than it does upon M/S benefits. MHPAEA is enforced by EBSA and CMS. Annually these agencies present a report to Congress which outlines the number of requests for comparative analysis made upon issuer and plan sponsors, and their related enforcement findings.

One area that EBSA investigates is key treatments for covered mental health conditions and substance use disorders, looking out for plans and service providers that may exclude these types of treatments. The purpose of MHPAEA is to ensure that where mental health and substance use disorder (“MH/SUD”) benefits are offered, that such benefits are offered on a comparable basis to medical and surgical (“M/S”) benefits. The EBSA has identified and inventoried several examples of key treatment limitations for MH/SUD benefits, such as the following examples:

1. Applied behavioral analysis (ABA) for autism spectrum disorder (ASD);
2. Medication-assisted treatment (MAT), or medication for opioid use disorder; and,  
3. Nutritional counseling for eating disorders.

After EBSA identifies any such exclusions within a plan or coverage, the issuer, service provider, and/or the plan sponsor must take certain corrective actions to remedy prohibited limitations upon MH/SUD benefits, such as:

1. Amending written plan terms to remove improper exclusion language;
2. Re-adjudicating previously denied claims resulting from the any improperly applied exclusion;
3. Re-processing any claims denied due to the application of the improper exclusion;
4. Providing notice of non-compliance to the plan’s participants and beneficiaries;
5. Changing governance and administrative related practices at both the plan and service provider levels, so as to remedy any such conflicts; and,
6. Ensuring any wrongly denied claims and/or appeals are re-processed and ultimately paid as covered benefits under the plan.

Another area that the EBSA evaluates is compliance with NQTLs, and specifically as related to the plan’s network adequacy and network composition. In order to perform the examination, EBSA reviews how plans and issuers create and monitor their networks and how they measure the impact of such practices as impacting the availability and uniformity of limitations respecting MH/SUD benefits (as compared to M/S benefits). In furtherance thereof, EBSA identifies and compares the number of times that patients utilize in network providers vs out-of-network providers. Where there is a disproportionate utilization of out-of-network providers, as compared to utilization of in-network providers, the EBSA considers this to be an enforcement red flag.

EBSA’s investigation of network composition necessarily incorporates the examination and review of methodologies for reimbursement rates applied to both in-network and out-of-network providers.[1] For example, EBSA’s review of a sample of claims paid under a plan demonstrated that the issuer paid M/S claims at 120% to 130% of Medicare reimbursement rates; however, the same plan paid MH/SUD benefit claims at 88% to 98% of Medicare reimbursement rates. When asked for clarification concerning the discrepancy, the issuer was unable to explain how the methodology generated the disparate rates.

EBSA also examined reimbursement rate disparities in the context of the plan sponsor’s or issuer’s development and monitoring of network composition. Where plan sponsors or issuers stated they relied upon network adequacy concerns as a factor in determining whether reimbursement rates were sufficient, they were unable to explain whether, and to what extent, they considered network adequacy in concert with the rate-setting processes (including respecting rate negotiations with providers). EBSA found multiple instances where plan sponsors and/or issuers actively increased reimbursement rates for certain M/S providers as a strategy to attract and retain service providers where they found insufficiency in the network; however, the same methodologies were not utilized to attract and retain MH/SUD providers, even where gaps were identified in MS/SUD provider networks.

While issuers are liable for assuring the MHPAEA sufficiency of fully insured product lines, plan sponsors of self- and level-funded plans are reminded that it is their responsibility to conduct and archive for production their written comparative analyses.

If you need assistance understanding and performing your MHPAEA obligations, reach out to the experts at The Baldwin Group today. 

Additional Information & Resources

• 2025 MHPAEA Report to Congress
• CMS MHPAEA Overview and resources
• DOL Self-Compliance Tool for MHPAEA
• DOL MHPAEA Investigations and Enforcement

[1] Plans and issuers utilize reimbursement rates as a methodology to encourage provider participation in a network.