Proposed Rule Could Strengthen Mental Health Coverage in 2025

Mitchell Kline

ID )) { ?>

The Internal Revenue Service, Employee Benefits Security Administration and the Health and Human Services Department have proposed amendments with the aim of bolstering enforcement of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). The agencies want to enhance patients' access to mental health and substance use disorder (MH/SUD) care and close existing loopholes that insurance companies often exploit to deny such care.

How the Mental Health Parity and Addiction Equity Act Could Change

The proposed changes in the rule released by the Departments of Labor and Health and Human Services could have a significant impact on individuals seeking mental health and substance use disorder (MH/SUD) care. Here's how these changes could affect a person:

1. Improved Access to Care: The proposed rule aims to ensure that individuals have better access to mental health and substance use disorder treatment. By clarifying and strengthening the requirements for parity between mental health benefits and medical/surgical benefits, it becomes more likely that people will receive the care they need.
2. Broader Coverage: The rule mandates that if a health plan provides treatment for a specific MH/SUD condition in one benefit classification (e.g., outpatient, in-network), it must provide treatment in all other benefit classifications. This means that individuals may have a broader range of treatment options and choices within their health plans.
3. Clearer Protections: The rule explicitly recognizes eating disorders and autism spectrum disorder as mental health conditions protected under the parity law. This means individuals with these conditions are more likely to receive insurance coverage for their treatment, potentially reducing the financial burden on them and their families.
4. Data-Driven Improvements: The requirement for plans and issuers to collect and evaluate data on the impact of nonquantitative treatment limitations (NQTLs) can lead to data-driven improvements in care access. If disparities in access are identified, plans will need to take "reasonable action" to address them. This could result in more equitable access to MH/SUD care for individuals.
5. Certainty in Coverage: With the proposed rule, individuals can have more confidence that their health plans will provide meaningful and equitable MH/SUD benefits. This certainty can alleviate concerns about denied claims or limited coverage for mental health and substance use disorder treatment.
6. Addressing Provider Shortages: The proposed rule includes an enforcement safe harbor for plans/issuers facing access disparities due to provider shortages. This may encourage health plans to work towards expanding their provider networks, ultimately improving access for individuals in areas with limited provider options.
7. Impact on Serious Mental Illness: The American Psychiatric Association has urged that meaningful benefits for serious mental illness include access to coordinated care, supported education, and supported employment. If the proposed rule leads to more comprehensive coverage, individuals with serious mental illness may receive the support they need to lead more fulfilling lives.

Key Provisions of the Proposed Rule

• Clarifying that the MHPAEA's purpose is to ensure that plan participants can access MH/SUD benefits on par with their medical/surgical benefits.
• Mandating that plans/issuers provide meaningful MH/SUD benefits across various benefit classifications.
• Recognizing eating disorders and autism spectrum disorder as mental health conditions protected under MHPAEA.
• Requiring plans/issuers to collect and assess outcome data to address material differences in accessing MH/SUD benefits compared to medical/surgical benefits.
• Demanding plans to demonstrate corrective action if their analyses reveal noncompliance with the parity law.
• Offering an exception for nonquantitative treatment limitations (NQTLs) when professional medical or clinical standards are applied impartially or to prevent fraud, waste, and abuse.
• Proposing an enforcement safe harbor for plans/issuers facing access disparities due to provider shortages, contingent upon reasonable efforts to expand their MH/SUD provider networks.
• Requiring NQTL comparative analyses to be certified by named fiduciaries who have reviewed the analysis.

The American Psychiatric Association expressed support for these measures but raised concerns regarding exceptions to non-quantitative treatment limitations (NQTLs) requirements and the consequences of non-compliance. The association also urged that meaningful benefits for serious mental illness include access to coordinated care, supported education, and supported employment.

Furthermore, the proposed rule seeks to amend regulations implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and establish new regulations for NQTLs comparative analyses under the Consolidated Appropriations Act, 2021.

These changes aim to prevent plans and issuers from imposing greater limits on MH/SUD benefits compared to medical/surgical benefits, emphasizing data collection and assessment. The rule also sets content requirements for NQTL comparative analyses and details how plans and issuers must share these analyses with relevant departments and authorities.

Additionally, the departments are soliciting input on ways to enhance mental health and substance use disorder coverage through other federal provisions. Finally, HHS proposes amendments to implement the sunset provision for self-funded, non-federal governmental plan elections to opt out of MHPAEA compliance, as adopted in the Consolidated Appropriations Act, 2023. The proposed rule is expected to take effect on January 1, 2025, for group health plans and on January 1, 2026, for individual health plans.