What’s the State of Mental Health Parity?
Q&A with Samantha Malovrh, Vice President of Compliance Consulting, OneDigital
Observers of the Mental Health Parity and Addiction Equity Act (MHPAEA) may have experienced regulatory whiplash in recent years.
The Biden administration in 2024 updated the MHPAEA to strengthen, reinforce, and codify some original regulations from the 2008 law. This was partially due to the lack of compliance by most businesses with rules prohibiting group health plans and insurers from restricting mental health and substance use benefits beyond restrictions applied to medical and surgical benefits.
Many of the changes involved the comparative analyses that are required of health plans’ non-quantitative treatment limitations (NQTLs) to ensure they adhere to the parity rules. The agencies that oversee the MHPAEA had found in 2023 and 2024 that none of the submitted comparative analyses complied with the legislation. The revised regulations included the mandate that coverage be “meaningful,” or offer a primary treatment for each covered condition, and that employers, or their plan sponsors, use quantifiable data to evaluate the NQTLs.
In January 2025, the ERISA Industry Committee (ERIC) filed a federal lawsuit challenging the 2024 updates, asserting the changes were illegal and unworkable for employers. The trade association claimed the comparative analysis requirements were too vague, that the federal agencies charged with overseeing the program aren’t qualified to determine what “meaningful benefits” are, and that the rule deprives plans of prior authorization and other tools used for decades to ensure benefits are “affordable and high quality.”
The Trump administration, in May 2025, requested that ERIC’s lawsuit be suspended while the oversight departments (Labor, Treasury, and Health and Human Services) reconsider the new amendments—and potentially rescind or modify them. The U.S. District Court for the District of Columbia quickly approved the request. While the administration undertakes this process (and for 18 additional months), it won’t pursue enforcement actions against organizations that don’t comply with the 2024 updates. The administration has recommended that states, which enforce fully insured and marketplace plans, follow the same approach.
The three federal agencies, in a joint statement, said they will continue to ensure people receive protections under the law in a way that is “not unduly burdensome for plans and insurers.”
In this interview, Malovrh, an executive with Atlanta-based insurance, financial services, and human resources consulting firm OneDigital, discusses the current state of play for MHPAEA regulations and how they might develop from here.
Q
What major changes were made to the MHPAEA in 2024?
A
The new final rules are pretty significant changes to the Mental Health Parity and Addiction Equity Act. They have a new fiduciary requirement and enhancements to what needs to be included in the comparative analysis. [Self-insured employers are the fiduciaries for their health plans, deciding which benefits to provide, fees to charge, and vendors to use. This makes them responsible for, among other things, plan parity requirements. If the plans aren’t compliant, these employers can be sued by employees who feel their benefits aren’t sufficient.]
Another big change was an expedited enforcement mechanism. Under the 2024 rules, when the administration requests a comparative analysis, a business has 10 business days to provide one. If they are found noncompliant, the employer or insurer has 45 days to specify how it will change the plan to become compliant. That was a big shift. [The 2021 iteration of the law allowed 45 days from the time of enactment for employers to provide their analysis.]
Q
How does the Trump administration move to freeze the litigation impact employers?
A
The employers are kind of in an area of limbo regarding which laws to comply with. But this doesn’t remove the rules of mental health parity. The mental health parity statute is still very much in effect. What just changed was some of the additional rules from 2024. And the federal departments in charge of enforcing the legislation have reviewed the comparative analyses like they have been required to do since 2021 to see if employers’ plans are in parity.
There’s also a heightened risk of private litigation, especially considering the trend of fiduciary lawsuits on the healthcare front. Employers need to ensure they’re complying with this law, because failing to comply opens them up to the risk of fiduciary breaches.
Employers have to look at what their employee population is requesting or demanding—what kind of access to additional mental health services employees need, because they have the right to voice that to their employers.
Samantha Malovrh, Vice President of Compliance Consulting, OneDigital
Q
Am I right that litigation under the MHPAEA tends to be from employees who think they should be covered for services that aren’t covered?
A
Yes. I hired someone here whose purpose was to help participants get access to the care that they thought would be covered under this act. I know that there are advocacy groups out there that help educate individuals about their rights and options under the mental health parity rule. So, employers probably have a higher risk from individuals who have been denied care that should have been covered under the parity rules filing litigation than they do being audited by the administration. That’s kind of where your bigger risk lies. And if the courts decide an employer is out of compliance, the employer has to modify their plan design to make sure they are in compliance with the rules.
Q
What are the compliance changes relative to the NQTLs?
A
Federal agencies like the Departments of Labor and Health and Human Services are required to request and review at least 20 analyses per year. That didn’t go away. What changed in 2024 was an enhancement of what needed to be included.
Internally, we were kind of worried about the new 2025 requirement that employers had to have fiduciary certification on the comparative analysis, because that is a complex piece. I don’t think many of our clients have the capability of doing the comparative analysis in-house. The process requires them to look at the plan and understand how claims are administered and how the plan operates. It’s very labor intensive—and above and beyond what our normal employers have access to, or that they have the knowledge or ability to do themselves. Employers are very much beholden to their TPA [third-party administrator] or their carrier to do the report, and there is often a hefty price to pay for that.
Q
What advice did you give employers to ensure they were meeting this standard before it was suspended?
A
The 2024 updates added more to what needed to be included in the comparative analysis. A lot of employers have been using the Department of Labor’s off-the-shelf online self-help tool to create a comparative analysis. Others are working with their vendors because carriers are responsible for complying with these rules. So often, we tell our clients to connect with their carriers or their TPAs to ensure that they are helping them complete a comparative analysis.
Q
If the goal is to ensure better behavioral health coverage, do some of these regulations ever get in the way or make it too complicated?
A
I think it’s just the nature of trying to figure out if the federal government, or any governing body, can change how health plans can be designed. Especially self-funded plans—their only course of action to change things is through the employer. States can go after carriers and make their own rules for insurance requirements. But on a federal level, we don’t have those mandates. It’s like they are trying to put enough pressure on employers that they push back on their carriers to change how things are covered. I don’t know if it’s the right way. I think maybe they’re trying to move the needle, but I don’t know if it’s enough. Because, yes, appropriate mental health coverage is very much an issue, and I do think it is still a top enforcement policy in the administration. They just have to go about it the right way, not going beyond what their authority is in designing these rules.
I think the main thing for employers to be aware of is that even though the 2024 changes are not being enforced, the core rules still apply. So, if you think that this doesn’t apply to you, if you are offering mental health and substance use disorder benefits, the mental health parity act is still applicable and in full force.
Samantha Malovrh, Vice President of Compliance Consulting, OneDigital
Q
What is your best guess regarding what the Trump administration will do as it reconsiders the rules?
A
I think, maybe naively, that they’re going to revisit the 2024 rules and try to bring them within the scope of the authority [of the oversight] agencies. I don’t necessarily think that they’re going to scrap them, because the Consolidated Appropriations Act of 2021 came out during the first Trump administration [and also made major changes to the MHPAEA]. So, I don’t see that it would be a priority for them to weaken the law. I think the parity act will continue; I don’t imagine they’ll shift course and completely pull back.
Q
Ultimately, what should employers know about ensuring they have robust behavioral health benefits?
A
It really comes down to an employer-by-employer basis. Employers have to look at what their employee population is requesting or demanding— what kind of access to additional mental health services employees need, because they have the right to voice that to their employers. There’s a lot of point solutions out there, or external vendors, that employers can add to their plans to make their mental health benefit offerings more robust.
There is a fundamental lack of enough providers or network access, especially if you go into more rural areas. But a lot of new vendors are popping up that can help fill those gaps. Even at OneDigital, we’ve added in additional mental health benefits to our existing benefit plans to really help address the needs of our employee population. I know others can do that, too.
Q
So, adding vendors to supplement the traditional plan can help employers meet the MHPAEA requirements?
A
Yes. Employers need to look at the plan that’s been offered to their employees. And adding supplemental benefits can help show they’re trying to bring the plan into parity if it isn’t already.
Q
Any final recommendations for employers regarding the parity laws?
A
I think the main thing for employers to be aware of is that even though the 2024 changes are not being enforced, the core rules still apply. So, if you think that this doesn’t apply to you, if you are offering mental health and substance use disorder benefits, the mental health parity act is still applicable and in full force. Employers just need to be on the lookout for the new regulations or laws that may be coming out after the administration considers the updates.
