Final Rules Released: What They Mean for Mental Health and Substance Use Disorder Benefits
By Nicolette Taber
Attorney
Dickinson Wright PLLC
Original Publish Date: October 01, 2024
On September 9, 2024, the Departments of Health and Human Services, Labor, and the Treasury (collectively “the Departments”) released final rules strengthening and clarifying the rules previously set forth in the Mental Health Parity and Addiction Equity Act (“MHPAEA”). These new rules signify the Departments’ commitment to enforcing existing mental health parity laws by imposing additional requirements on insurers while also outlining guidelines for compliance.
The final rules reinforce the MHPAEA’s mandate of group health plans and health insurance issuers that offer group and individual health insurance coverage of mental health or substance use disorder benefits to do so in parity with medical and surgical benefits. The MHPEAEA prohibits imposing more significant restrictions on mental health or substance use disorder benefits as compared to medical and surgical benefits. Since the passing of the MHPAEA in 2008, however, the Departments have noted through their audits of group health plans and health insurance issuers that many beneficiaries still encountered barriers to accessing mental health and substance use disorder care compared to medical and surgical care. Therefore, the Departments issued these new final rules to address this discrepancy.
The new rules also reinforce the prohibition of group health plans’ and issuers’ use of more restrictive, nonquantitative treatment limitations (NQTL) for mental health and substance use disorder benefits. NQTLs are non-numerical restrictions on the scope or duration of benefits, such as requiring prior authorization or provider network standards, which can make it more difficult for individuals to access healthcare. The final rules codified the requirement set forth in MHPAEA that issuers conduct comparative analyses to measure the impact of NQTLs, including evaluating standards related to network composition, out-of-network reimbursement rates, and medical management and prior authorization NQTLs. The final rules also prohibit the use of discriminatory information or evidence that disfavor access to mental health or substance use disorder benefits as compared to medical/surgical benefits when plans/issuers design NQTLs. These final rules seek to ensure group plans and issuers do not use NQTLs that place greater restrictions on access to mental health and substance use disorder benefits as compared to medical/surgical benefits. Notably, the final rules also require plans and issuers to collect and evaluate relevant data reasonably designed to assess the impact of NQTLs on outcomes related to access to mental health and substance use disorder benefits and medical/surgical benefits. That data must be used, as necessary, to address material differences in access to mental health or substance use disorder benefits and remove any barriers to access.
The Departments also finalized the “meaningful benefits” standard, which requires that if a plan or health insurance coverage provides any benefits for a mental health condition or substance use disorder in any classification of benefits, it must provide meaningful benefits for that said condition in every classification in which medical/surgical benefits are provided. In short, this means that plans/issuers must cover the core treatment for a given condition or disorder, whether it is a physical or mental health condition/disorder, based on generally recognized independent standards of current medical practice.
The Final Rule generally applies to group health plans and group health insurance coverage on the first day of the first plan year beginning on or after January 1, 2025. However, certain portions of the regulations’ requirements, including 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 beginning on or after January 1, 2026.
These new rules will likely face imminent legal challenges. Given the Supreme Court’s recent ruling in Loper Bright Enterprises v. Raimondo (which overturned the longstanding Chevron doctrine of deferring to agencies’ reasonable interpretations of ambiguous laws), it is unclear how the courts would respond to the challenging of the application of these MHPAEA final regulations. In the interim, insurers should work closely with their legal counsel to ensure compliance with the regulations that have already been finalized for the 2025 plan year.
Critics of these final rules have voiced concerns that the rules may actually limit access to mental health care or substance use disorder benefits if the group plans opt to drop the benefits entirely. The Departments have also faced criticism for issuing these final rules while not addressing healthcare workforce shortages. With respect to this latter issue, on September 17, 2024, the Health Resources and Services Administration (HRSA), an agency of HHS, announced nearly $100 million in awards to increase health care providers and behavioral health support. HRSA’s awards include more than $63 million to 32 organizations dedicated to improving the number of peer support specialists, community health workers, and other community-based providers while also providing mental health services and support to individuals impacted by opioid use disorders and other substance use disorders. HRSA is also awarding nearly $12 million to three medical schools to help increase the number of primary care physicians in medically underserved communities.
Nicolette Taber is an attorney at Dickinson Wright in Chicago. She represents health care clients in a variety of regulatory and corporate matters. With experience in medical malpractice defense, Nicolette brings a comprehensive understanding of the health care landscape. During law school, she interned in the offices of general counsel at two Chicago hospitals. Growing up in a family of health care providers has equipped her with a unique perspective on her clients' needs. She can be reached at ntaber@dickinsonwright.com.