The Departments of Labor, Health and Human Services, and the Treasury (the “Departments”) recently released their 2025 Report to Congress on enforcement activity under the Mental Health Parity and Addiction Equity Act (“MHPAEA”).

Background

MHPAEA is a federal law that generally requires group health plans and health insurance issuers that provide mental health or substance use disorder benefits to provide those benefits on terms no more restrictive than the terms applicable to medical and surgical benefits. This parity requirement extends to both financial requirements, such as copayments and coinsurance, and treatment limitations.

Treatment limitations under MHPAEA may be either quantitative treatment limitations (QTLs), which are numerical in nature (such as visit limits and day limits), or non-quantitative treatment limitations (NQTLs), which are non-numerical limits on the scope or duration of benefits for treatment. Examples of NQTLs include prior authorization requirements and other medical management techniques, standards for provider admission to participate in a network (including reimbursement rates), formulary design for prescription drugs, and restrictions based on geographic location, facility type, or provider specialty.

The Consolidated Appropriations Act of 2021 (CAA, 2021) amended MHPAEA to expressly require health plans and issuers to perform and document comparative analyses of the design and application of their NQTLs. In general, these comparative analyses must demonstrate that the processes, strategies, evidentiary standards, and other factors used to apply an NQTL to mental health and substance use disorder benefits, both as written and in operation, are comparable to and applied no more stringently than those used for medical/surgical benefits.

The Departments are required to submit an annual report to Congress regarding NQTL comparative analysis enforcement, in addition to a biennial report to Congress on MHPAEA compliance more broadly. These reports summarize the Departments’ enforcement efforts, outline the comparative analyses collected from plans and issuers, and describe findings of noncompliance with MHPAEA.

2025 Report

The 2025 Report covers the Departments’ enforcement activities during the two-year period from August 1, 2023, through July 31, 2025. The Departments made clear that MHPAEA’s statutory obligations, including the requirement to perform and document comparative analyses continue to have effect. As we highlighted in a previous article on the Department of Labor’s (DOL) enforcement priorities, MHPAEA will continue to be an area of focus for the DOL in 2026.

Highlights of Key Metrics: 

• Both the DOL and the Centers for Medicare & Medicaid Services (CMS) issued more requests for comparative analyses signaling that enforcement was active in the two year period.
• The DOL engaged in less correspondence with health plans and issuers about the NQTLs at issue, but also issued more initial determination letters[1] in the same time period. This indicates that the DOL proceeded with citing MHPAEA violations while asking fewer questions.
• In contrast to the DOL, CMS issued far more insufficiency letters meaning that CMS engaged in far more correspondence with plans and issuers. CMS noted there were many times where there was no comparative analysis, and that additional information was still needed even after reviewing the comparative analyses.
• Both the DOL and CMS issued more final determination letters in 2025 than in prior years showing that they are increasingly willing to cite a plan or issuer in the report to Congress for providing deficient comparative analyses.
• Employers should continue to pay careful attention to the following specific types of NQTLs that continue to draw the most scrutiny from the Departments:
  • Provider network admission standards,
  • Prior authorization requirements,
  • Concurrent care review requirements, and
  • Exclusions of key mental health and substance use disorder treatments (such as ABA therapy, methadone maintenance treatment, and nutritional counseling for eating disorders).

Thompson Hine Takeaways

The 2025 Report reinforces several practical takeaways for employers sponsoring group health plans.

1. MHPAEA compliance is the plan sponsor’s responsibility, even when benefit administration is outsourced to service providers such as third-party administrators or pharmacy benefit managers. Employers should proactively discuss MHPAEA and NQTL compliance obligations with their service providers, and continue to request and review comparative analyses from their vendors.
   
   In addition, employers should confirm that the documents used by third party administrators (“TPAs”) to capture the plan design for internal administration purposes are consistent with the terms described in the benefits booklets and summary materials provided to participants.  In other words, ensure the TPA is actually administering the plan in accordance with the intended terms of the plan, and ensure plan documents, SPDs, and benefit descriptions accurately describe the processes applied by the TPA.
   
   Employers should take note of commonly cited NQTL violations and review TPA administrative practices and procedures to evaluate risk. The 2025 report specifically included several failures related to service provider performance. For instance, one service provider used outdated legacy systems that were noncompliant with MHPAEA, which affected multiple plans, resulting in the need to reprocess and pay previously denied claims. In another example, a service provider administered an ABA therapy exclusion to self-funded plans that included Autism Spectrum Disorder as a covered mental health benefit, a practice the DOL has long signaled to be viewed as a de facto MHPAEA violation.
   
   Finally, the report referenced concerns about carveout arrangements, suggesting that plans must review information from all service providers to ensure the comparative analyses have meaningful comparisons.
   
2. Proactively preparing thorough, well-documented comparative analyses is not merely a regulatory nicety – it is a practical imperative. When plans prepared complete comparative analyses as required, investigations were resolved more quickly and led to better outcomes. Conversely, deficient comparative analyses significantly prolonged investigations, sometimes spanning multiple years and involving multiple rounds of document requests, subpoenas, and depositions. Previous reports to Congress have set forth detailed lists of deficiencies noted in comparative analyses, including:
   
   • failure to document a comparative analysis before designing and applying an NQTL,
   • conclusory assertions lacking specific supporting evidence or detailed explanation,
   • lack of meaningful comparison or analysis,
   • provisions of documents without adequate explanation of relevance, and
   • focusing only on similarities—rather than explaining differences—to show parity.
   
   
3. MHPAEA’s statutory obligations, including the obligation to produce written NQTL comparative analyses, remain fully in effect. A recent non-enforcement policy applicable to certain MHPAEA regulatory requirements left some with the false impression that all MHPAEA enforcement was paused.  In 2024, the Departments issued a final rule (“the 2024 MHPAEA final rule”)[1] that amended prior MHPAEA regulations issued in 2013[2] and added new regulation to implement the CAA, 2021 NQTL comparative analyses requirements.  The 2024 MHPAEA final rule was swiftly challenged in a federal lawsuit (previously discussed here).  In May 2025, in response to that lawsuit, the Departments issued a non-enforcement policy[3] stating they will not pursue enforcement actions for failure to comply with the 2024 MHPAEA final rule while the lawsuit is pending, plus an additional 18 months after its resolution. The non-enforcement policy applies only to those portions of the 2024 final rule that are new in relation to the 2013 final regulations, and it expressly does not apply to MHPAEA’s statutory obligations, including the obligation to produce NQTL comparative analyses.  Therefore, employers should not interpret this interim posture as a signal that enforcement has paused. As the 2025 Report makes clear, the Departments continue to aggressively investigate and cite violations under existing statutory authority.[4]

Why it Matters

Employers who take steps now to audit their plans’ NQTL compliance, make good faith efforts to produce complete and well supported analyses, clarify responsibilities with their service providers, and ensure comparative analyses accurately reflect the plan’s design and administration, will be best positioned to avoid the costly and time-consuming enforcement actions that the Departments continue to pursue. Those efforts will also be useful in defending potential MHPAEA NQTL litigation.

If you have any questions, please contact the authors or your Thompson Hine attorney.

---

[1] The initial determination letter cites a MHPAEA violation, but gives the plan or issuer an opportunity to provide a corrective action plan without being directly named in the report to Congress.

[2] 89 Fed. Reg. 77586 (Sept. 23, 2024).

[3] 78 Fed. Reg. 68240 (Nov. 13, 2013).

[4] Statement of U.S. Departments of Labor, Health and Human Services, and the Treasury regarding enforcement of the final rule on requirements related to the Mental Health Parity and Addiction Equity Act (May 15, 2025).

[5] Recently, in a joint status report filed in the litigation challenging the 2024 final rule, the Departments explained that they will no longer defend the 2024 rule and instead will issue a new proposed rule no later than December 31, 2026. Consistent with the 2025 Report, the Departments’ statement of intention to propose new rules reflects their ongoing commitment to focus on MHPAEA.