Prioritizing Mental Health Means Ensuring Comprehensive Coverage and Services

Lately, there's been a lot of discussion about the importance of prioritizing mental health. But if you or a loved one have ever struggled to find a mental health provider for someone in crisis or faced challenges getting care for conditions like eating disorders, substance use disorders, or autism spectrum disorders, you know getting coverage for these services can range from difficult to impossible.

Thankfully, the Departments of Labor, Treasury and Health and Human Services recently jointly released new mental health and addiction parity rules to close these coverage gaps and ensure people can get the treatment they need and deserve. In January 2025, these new rules will begin to go into effect for private insurance covering workers and their families (including private insurance plans offered by large and small employers as well as plans for federal, state, and local government workers). They will go into effect for health plans sold to individuals in January 2026.

Pursuant to the Mental Health Parity and Addiction Equity Act, the new rules offer more protections by ensuring employer-sponsored and privately purchased individual insurance plans make care for mental health and substance use disorders as accessible as care for other medical conditions. (Note: These new rules do not apply to Medicaid and CHIP programs, but Medicaid and CHIP also must abide by the Mental Health and Addiction Equity Act. Resources and compliance tools for them are here. CMS is currently requesting comments on how these plans should document compliance.)

The rules also include examples of what equitable treatment entails, including the following:

• Plans must collect and analyze data on how their practices limit access to mental health and substance use disorder treatment as compared to physical health. Where there are disparities in access, plans must take actions to reduce those disparities.
• Plans that cover core treatments for medical and surgical procedures must cover them for mental health and substance use disorders, in accordance with independent, objective standards and clinical guidelines. For example:
  • Coverage of treatment for autism disorders must include coverage of applied behavioral analyst therapy - a core treatment recognized by independent medical standards.
  • Plans that cover prescription drugs for other conditions must also cover medications to treat opioid disorders, along with counseling and behavioral therapies.
  • Plans that cover nutrition counseling for diabetes and obesity must also cover nutrition counseling for people with eating disorders.
• Plans can't deviate from generally accepted standards of care if a plan states that it relies on such standards for physical health. For example, in such circumstances:
  • Plans can't require monthly prior authorization of buprenorphine and naloxone because the American Society of Addiction Medicine does not support this in its treatment guidelines.
• The rule makes significant strides in requiring plans to offer an adequate network of available providers and service and help locating them. For example:
  • In-network providers should be as accessible for people with mental health and substance use disorders as they are for people with other health problems.
  • Plans must examine their networks to make sure that providers specializing in mental health and addiction treatment are available in-network, within reasonable travel times and distances, and are accepting new patients.
  • Plans should strengthen provider recruitment, expand telehealth services, ensure that their provider directories are accurate, and provide outreach to help patients find available in-network providers and facilities if their networks are not sufficient.

To ensure plans are meeting these requirements, they will have to conduct annual "comparative analyses" of treatment limits that apply to mental health and substance use care as compared to medical and surgical care and submit data to regulators.

Raising Awareness and Getting Help

Families USA applauds the Mental Health Leadership Group and the many advocates and organizations who worked to make these protections a reality. Now, we all have roles to play in spreading the word.

• Even before the new rules go into effect, people who are experiencing barriers obtaining mental health and substance use benefits should consult consumer assistance programs, advocates, and/or regulatory agencies as many legal protections already apply.
• Share these helpful resources and tools from the Department of Labor.