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On September 9, 2024, the Departments of Labor, Health and Human Services, and the Treasury released new final rules to strengthen parity between mental health and substance use disorder (MH/SUD) benefits and medical and surgical (M/S) benefits.
The Mental Health Parity and Addiction Equity Act (MHPAEA) prohibits health plans and health insurance companies from imposing greater restrictions on MH/SUD benefits than on M/S benefits. This includes financial requirements such as copays and treatment limitations such as visit limits or prior authorization requirements.
The new rules better ensure that plans and companies comply with MHPAEA. They also allow providers to obtain more information from these plans and companies about how nonquantitative treatment limitations comply with the requirements.
For patients with group health coverage, the new rules will generally begin to apply on January 1, 2025, though plans and companies will be given until January 1, 2026, to comply with certain new standards. For patients with individual health insurance coverage (i.e., Marketplace), the new protections will generally begin to apply on January 1, 2026.
Although some of the new rules do not take effect right away, MHPAEA and existing regulations still provide protections for patients seeking MH/SUD treatment and will continue to be enforced.
They can call the Employee Benefits Security Administration toll-free at (1 866) 444-3272 or contact us at askebsa.dol.gov.
They can also contact the Centers for Medicare & Medicaid Services through the No Surprises Help Desk available at (1 800) 985-3059 or via webform at www.cms.gov/nosurprises/consumers/complaints-about-medical-billing.
Providers can expect how health plans and health insurance companies define MH conditions and SUDs to be consistent with the most current version of the International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders.
Providers can expect that their patients' MH/SUD coverage will no longer be designed using information, evidence, sources, and standards that discriminate against MH conditions and SUDs.
Providers can expect reasonable action as necessary from plans and companies if data, such as claims denials, in-network and out-of-network utilization rates, and provider reimbursement rates, they collect and evaluate shows material differences in access to MH/SUD benefits as compared to M/S benefits.
Providers can expect to see the following types of changes if plans and companies need to improve access to MH/SUD providers, including but not limited to:
Providers can expect plans and companies to cover meaningful benefits (including a core treatment) for each covered MH condition and SUD if benefits are covered for medical conditions or surgical procedures in the same benefit classification (e.g., inpatient, in-network; outpatient, in-network; emergency).
Providers can generally request written documentation of their patients' plans' and insurance companies' compliance with MHPAEA, if they are acting as authorized representatives for their patients in connection with denied claims.
