The U.S. Department of Labor (DOL) recently issued guidance describing how its Employee Benefits Security Administration (EBSA) will focus its enforcement efforts under the Mental Health Parity and Addiction Equity Act (MHPAEA).

MHPAEA generally requires health plans that cover mental health and substance use treatment to provide those benefits on terms that are no more restrictive than the terms that apply to medical and surgical care. For example:

• If a plan requires a copay for a doctor’s office visit, it generally cannot impose a higher copay for a mental health office visit in the same category of care.

• If a plan places limits on the number of medical or surgical visits, similar limits generally cannot be applied more restrictively to mental health or substance use treatment.

• If a plan requires prior authorization for certain medical or surgical services, similar requirements for mental health or substance use services must comply with the same parity standards.

The guidance does not require employers to make changes to their health plans simply because the DOL issued this bulletin. It instead provides insight into the areas EBSA intends to prioritize when conducting MHPAEA investigations. The DOL's updated enforcement approach places particular emphasis on three areas involving nonquantitative treatment limitations (NQTLs). The DOL will focus on whether:

• Mental health and substance use disorder treatments are being excluded when similar medical treatments are covered.

• Mental health and substance use disorder patients face extra requirements, such as prior authorization, that do not similarly apply to medical patients.

• Patients have reasonable access to mental health and substance use disorder providers through the plan's network.

The DOL also clarified that it will continue to enforce the underlying MHPAEA requirements. Plans must continue to maintain required comparative analyses for NQTLs and be prepared to provide those analyses to the federal agencies upon request. The DOL may also investigate other MHPAEA issues that come to the DOL's attention through participant complaints or DOL reviews.

Mental health services are an increasingly important part of employer-sponsored health coverage.

• 22% of employers with 50–199 employees and 48% of employers with 200+ employees reported that the percentage of employees receiving mental health services increased over the prior year in KFF's employer survey.

• In the same survey, 6% of smaller employers and 14% of larger employers reported an increase in employees receiving substance-use treatment.

• More recently, KFF's 2024 Employer Health Benefits Survey found that 23% of employers with 50+ employees took steps to add in-network telehealth providers for mental health or substance-use services, while 14% took steps to add in-person providers.

Many Employee Assistance Programs (EAPs) are treated as “excepted benefits” and are generally not subject to MHPAEA. However, an EAP cannot be used as a more restrictive gateway to mental health or substance use treatment. For example, a health plan generally cannot require an employee to use or exhaust EAP counseling benefits before the employee can access covered mental health treatment under the medical plan if there is no comparable requirement for medical/surgical benefits.

C2 will continue to monitor developments related to MHPAEA and will provide additional information if further guidance results in changes that require client action.