MHPAEA Enforcement Paused: What the 2026 Delay Means for Behavioral Health Providers

Background: The Long Road to Parity Enforcement

The Mental Health Parity and Addiction Equity Act was signed into law in 2008, building on the earlier Mental Health Parity Act of 1996. Its core requirement is straightforward: health plans that offer mental health and substance use disorder benefits must cover them on terms no more restrictive than medical and surgical benefits. This applies to financial requirements (copays, deductibles, out-of-pocket limits), quantitative treatment limitations (visit limits, day limits), and nonquantitative treatment limitations (prior authorization requirements, network admission standards, step therapy protocols, reimbursement rates, fail-first policies, and other utilization management techniques).

For quantitative limitations, parity is relatively easy to measure. If a plan limits outpatient medical visits to 30 per year, it cannot limit outpatient behavioral health visits to fewer than 30 per year. The math is simple.

For nonquantitative treatment limitations (NQTLs), parity has been far harder to define, measure, and enforce. Prior authorization is the most consequential example. A plan might require prior authorization for outpatient behavioral health visits after the third session while not requiring prior authorization for comparable outpatient medical visits at all. The plan would argue that the clinical criteria for behavioral health services justify the additional oversight. Patient advocates and providers would argue that the differential prior authorization burden violates parity. Without a standardized framework for evaluating these arguments, enforcement was inconsistent and largely complaint-driven.

The 2024 MHPAEA final rule (89 FR 77586), published on November 22, 2024, was designed to close this enforcement gap. It required health plans to conduct and document comparative analyses of every NQTL applied to MH/SUD benefits, demonstrating through data and methodology that the NQTL was no more restrictive for MH/SUD than for medical/surgical services. Plans were required to have these analyses completed by January 1, 2025, and to make them available to regulators and participants upon request.

What Happened: The Enforcement Pause and Legislative Delay

The CMS/DOL Enforcement Pause

In early 2025, CMS and the Department of Labor announced that they would not enforce the NQTL comparative analysis requirement while they developed additional sub-regulatory guidance on compliance. The agencies cited the complexity of the comparative analysis requirement, the volume of questions from health plans about methodology, and the need for a transition period to allow plans to develop the analytical infrastructure needed for compliance.

The enforcement pause was framed as a temporary measure to ensure fair implementation. In practice, it removed the primary accountability mechanism that the 2024 final rule was designed to create. Plans that had not begun comparative analyses had no immediate consequence for inaction. Plans that had identified parity violations through their analyses had no regulatory pressure to remediate them.

The One Big Beautiful Bill Act (OBBBA)

The "One Big Beautiful Bill" Act, passed by Congress in 2025, included provisions that further delayed MHPAEA enforcement mechanisms. While the OBBBA is primarily a budget reconciliation bill covering tax, energy, and immigration policy, it included healthcare provisions that extended the enforcement pause for the NQTL comparative analysis requirements and modified the timeline for certain compliance obligations under the 2024 final rule.

The legislative delay means that even if CMS and DOL were to lift their enforcement pause, the OBBBA provisions create an additional statutory delay before full enforcement can resume. The combined effect of the regulatory pause and the legislative delay is that there is no confirmed date for enforcement of the NQTL comparative analysis requirement.

What This Does Not Change

It is critical to understand what the enforcement pause does and does not affect:

• MHPAEA itself is still law: The underlying parity requirement has not been repealed, amended, or weakened. Health plans are still legally required to maintain parity in financial requirements, quantitative treatment limitations, and nonquantitative treatment limitations.
• Individual complaints can still be filed: The Department of Labor, CMS, and state regulators continue to accept and investigate individual parity complaints. The enforcement pause applies to the proactive comparative analysis requirement, not to the reactive complaint investigation process.
• State parity laws are unaffected: Over 40 states have enacted their own parity laws, many of which exceed MHPAEA requirements. State insurance departments, attorneys general, and state legislatures are not bound by the federal enforcement pause.
• Litigation continues: Private lawsuits challenging parity violations continue in federal and state courts. The Wit v. United Behavioral Health litigation and similar cases have resulted in significant rulings on parity compliance that are not affected by the enforcement pause.

What This Means for Behavioral Health Providers

The enforcement pause has three practical consequences for behavioral health providers: parity violations continue at current levels, the data-driven enforcement mechanism is delayed, and the financial burden of parity gaps remains with providers and patients.

Prior Authorization Disparities Continue

Prior authorization is the NQTL with the most direct impact on behavioral health revenue. Current data shows that behavioral health services face prior authorization requirements at approximately three times the rate of comparable medical and surgical services. Specific disparities include:

• Outpatient therapy: Most commercial plans require prior authorization for outpatient behavioral health visits after an initial evaluation period (typically 3 to 8 sessions), while comparable outpatient medical visits (e.g., physical therapy, outpatient cardiology follow-up) do not require prior authorization at all or have significantly higher thresholds.
• Intensive outpatient programs (IOP): Authorization for IOP is typically required before the first session and renewed every 1 to 2 weeks. Comparable medical IOPs (e.g., cardiac rehabilitation, pulmonary rehabilitation) often have initial authorizations covering 12 to 36 sessions with less frequent renewal requirements.
• Residential treatment: Residential SUD treatment requires concurrent review every 3 to 7 days at most payers. Comparable medical residential stays (e.g., skilled nursing facility rehabilitation) often receive initial authorizations of 14 to 30 days with less frequent concurrent review.
• Medication-assisted treatment (MAT): Prior authorization for buprenorphine, naltrexone, and other MAT medications remains common despite the 2023 Consolidated Appropriations Act prohibition on Medicaid prior authorization for MAT. Commercial plans continue to impose step therapy and prior authorization on MAT medications that are not applied to comparable chronic disease medications.

Each of these prior authorization disparities imposes direct costs on behavioral health providers: staff time to submit authorization requests, clinical time diverted to peer-to-peer reviews, revenue delays while authorizations are processed, and lost revenue when authorizations are denied or lapse.

Network Adequacy Gaps Persist

The NQTL comparative analysis was expected to address network adequacy, one of the most significant structural barriers to behavioral health access and provider revenue. The current landscape:

• Ghost networks: Studies consistently show that 30% to 50% of providers listed in behavioral health directories are not actually available, not accepting new patients, or no longer at the listed address. This inflates apparent network adequacy while patients cannot access in-network care.
• Reimbursement-driven network attrition: Behavioral health providers are reimbursed at rates 10% to 30% lower than medical/surgical providers for services of comparable complexity, creating a financial disincentive to participate in insurance networks. The resulting narrow behavioral health networks force patients out-of-network, shifting costs to patients and reducing provider revenue certainty.
• Geographic access disparities: In rural and underserved areas, behavioral health network adequacy is significantly worse than medical/surgical network adequacy. Plans that meet time-and-distance network adequacy standards for medical/surgical providers often fail the same standards for behavioral health providers but face no consequence.

Without the comparative analysis requirement forcing plans to quantify and address these network adequacy gaps, the status quo continues. Behavioral health providers lose potential patients to out-of-network barriers, and patients lose access to care.

What Your Billing Team Needs to Do

The enforcement pause does not mean there is nothing to do. In fact, the pause creates an opportunity to build the documentation and data infrastructure that will be essential when enforcement resumes, and that can drive revenue recovery through state-level channels right now.

1. Document every parity violation systematically. Create a parity violation log that records every instance where a behavioral health service faces a more restrictive NQTL than a comparable medical/surgical service at the same payer. Track prior authorization requirements (BH services that require PA when comparable med/surg services do not), authorization timeframes (BH authorizations with shorter approval windows), concurrent review frequency (BH services reviewed more frequently), denial rates by service type (compare BH denial rates to med/surg denial rates for the same payer), and reimbursement rate differentials. This log becomes evidence for state-level complaints, contract negotiations, and future federal enforcement.
2. File state-level parity complaints for documented violations. Every state with a parity enforcement mechanism can receive and investigate complaints. Prioritize complaints in states with the strongest enforcement track records: Connecticut, California, Illinois, Massachusetts, New York, and Oregon have all demonstrated active parity enforcement. Include specific data: the payer, the behavioral health service subject to the NQTL, the comparable medical/surgical service that does not face the same limitation, and the financial impact.
3. Track denial rates by service type and payer. Build a dashboard or report that compares denial rates for behavioral health services against denial rates for medical/surgical services at each payer. Break this down by denial reason: prior authorization denials, medical necessity denials, network-related denials, and administrative denials. This data-driven approach mirrors the comparative analysis that plans were supposed to conduct and provides objective evidence of parity violations.
4. Use contract renegotiation to address parity gaps directly. When payer contracts come up for renewal, use parity as a negotiating point. If a payer requires prior authorization for outpatient therapy but not for outpatient physical therapy, that is a parity issue that can be raised in contract negotiations regardless of whether federal enforcement is active. Present data on the financial impact of the disparity and request specific contract terms that align behavioral health NQTLs with medical/surgical NQTLs.
5. Monitor reimbursement rate parity. Compare your contracted rates for behavioral health services against published rates for medical/surgical services of comparable complexity (measured by RVU, time, and clinical complexity). If your organization is reimbursed at $90 for a 60-minute behavioral health visit while a comparable 60-minute medical visit is reimbursed at $130 by the same payer, document the disparity. Rate parity is an NQTL issue that the 2024 final rule specifically addressed and that state-level enforcement can act on.
6. Engage with professional associations. Organizations including the American Psychological Association, the National Council for Mental Wellbeing, the National Association of Addiction Treatment Providers, and state-level behavioral health associations are actively tracking the enforcement pause, filing amicus briefs in parity litigation, and lobbying for enforcement resumption. Participate in these efforts and contribute data from your parity violation documentation.
7. Prepare for enforcement resumption. The enforcement pause is described as temporary. When it ends, plans will be required to complete comparative analyses and remediate violations. Providers who have documented parity violations during the pause will be positioned to file complaints, pursue state-level enforcement, and challenge plans that have used the pause to maintain discriminatory NQTLs. Build the documentation now so it is ready when enforcement resumes.

Revenue and Financial Impact

The financial impact of the enforcement pause is not theoretical. Parity violations have a quantifiable effect on behavioral health revenue, and the enforcement pause extends the timeline during which these revenue losses continue without a regulatory correction mechanism.

Breaking down the revenue impact by NQTL category:

• Prior authorization denials: 4% to 8% of BH claims. Behavioral health prior authorization denial rates run approximately 4% to 8% of submitted claims, compared to 1% to 3% for comparable medical/surgical services. For a practice billing $2 million annually, this disparity represents $60,000 to $100,000 in annual revenue at risk. Even when denials are overturned on appeal, the administrative cost of the appeal process ($25 to $118 per appeal per AMA estimates) and the 30 to 90 day payment delay have real financial impact.
• Network adequacy and out-of-network leakage: 8% to 15% of potential revenue. When plans maintain narrow behavioral health networks, potential patients who could be treated in-network instead go out-of-network or forgo care entirely. For providers in-network, the narrow network may limit referral volume. For providers out-of-network, higher patient cost-sharing reduces the effective collection rate. Both scenarios represent revenue that would exist under a parity-compliant network.
• Reimbursement rate differentials: 10% to 30% lower per service. When behavioral health services are reimbursed at 70 to 90 cents on the dollar compared to medical/surgical services of equivalent complexity, the revenue impact compounds across every claim. For a practice billing 15,000 claims per year at an average underpayment of $15 per claim, the annual impact is $225,000.

Modeling the Enforcement Delay Cost

Every month that enforcement is paused extends the period during which these revenue losses continue uncorrected. If enforcement had proceeded on schedule (January 1, 2025), plans would have been required to identify and remediate parity violations by now. Each month of delay at $12 billion in annual industry-wide impact represents approximately $1 billion in continued parity-related revenue losses across the behavioral health system.

For individual practices and programs, the calculation is simpler: multiply your estimated annual parity-related revenue loss by the number of months the pause continues. A practice losing $250,000 annually to parity violations will lose an additional $20,800 for each month enforcement is delayed. This is not speculative loss; it is the continuing cost of documented, measurable parity gaps that enforcement was designed to close.

EHR and Technology Implications

Even with enforcement paused, behavioral health providers should be using their EHR and practice management systems to build the documentation infrastructure needed for parity enforcement, whether that comes through federal resumption, state-level action, or contract negotiation.

• Denial tracking and categorization: Your EHR or practice management system should track every denial by payer, service type, denial reason, and outcome (overturned, upheld, written off). This data is the foundation for identifying parity violations. Platforms like AZZLY Rize and Ease include denial analytics that can categorize denials by behavioral health vs. medical/surgical to surface parity patterns, making it easier for RCM teams to build evidence for parity complaints.
• Prior authorization workflow tracking: Track which services require prior authorization at each payer, how long authorization takes, the approval/denial rate, and the staff time expended on each authorization. Compare this against medical/surgical authorization requirements at the same payer to quantify the NQTL disparity.
• Reimbursement rate analysis: Use your billing system to compare contracted rates for behavioral health services against medical/surgical rates at the same payer. Many practice management systems can generate reports showing allowed amounts by CPT code and payer, which can be compared against published medical/surgical rates.
• Automated complaint data export: When filing state-level parity complaints, you will need to provide specific data on the services affected, the NQTLs imposed, and the financial impact. Your EHR should be able to export this data in a format suitable for regulatory submissions.
• Network adequacy documentation: Track patient referrals that could not be completed due to network inadequacy, patients who report difficulty finding in-network behavioral health providers, and wait times for behavioral health appointments compared to medical appointments. This qualitative and quantitative data supports network adequacy parity complaints.
• Contract compliance monitoring: Track whether payers are adhering to contracted terms, including authorization timeframes, clean claim payment timelines, and fee schedule rates. Deviations from contracted terms may themselves be parity violations if they disproportionately affect behavioral health claims.

State-Level Enforcement: Where to Focus

With federal enforcement paused, state-level enforcement is the primary mechanism for addressing parity violations. The following states have demonstrated the most active parity enforcement and represent the best opportunities for providers to pursue complaints:

State	Enforcement Agency	Key Strengths
California	DMHC / CDI	SB 855 (2020) requires parity compliance for all commercial plans; active investigation and enforcement; IMRs for parity-related denials.
Connecticut	Insurance Department	Conducts proactive parity compliance examinations of insurers; published enforcement reports with plan-specific findings.
Illinois	DOI	SB 1707 requires NQTL data reporting; active enforcement with fines for non-compliance.
Massachusetts	DOI / AGO	Strong AG enforcement; consent decrees with major insurers; HPC cost transparency reporting.
New York	DFS	Timothy's Law provides broad parity protections; active DFS enforcement; ombudsperson program for parity complaints.
Oregon	DCBS	HB 2024 (2023) requires proactive NQTL reporting; active investigation of network adequacy parity.

Providers in states not listed above should check their state insurance department website for parity complaint processes and their state behavioral health association for enforcement activity. Even in states with less active enforcement, documented complaints create a record that informs future enforcement and legislative action. For state-specific guidance on behavioral health compliance and billing, see our state practice guides.

Frequently Asked Questions

What is the MHPAEA and what did the 2024 final rule require?

The Mental Health Parity and Addiction Equity Act is a federal law requiring health plans that offer mental health and substance use disorder benefits to cover them at parity with medical and surgical benefits. The 2024 final rule strengthened MHPAEA by requiring health plans to conduct documented comparative analyses of nonquantitative treatment limitations (NQTLs), such as prior authorization requirements, network admission standards, and step therapy protocols, to prove that these limitations are no more restrictive for behavioral health than for medical/surgical services. Plans were required to complete these analyses by January 1, 2025.

Why was enforcement of the NQTL comparative analysis requirement paused?

CMS and DOL paused enforcement in early 2025, citing the complexity of compliance and the need for additional sub-regulatory guidance. The One Big Beautiful Bill Act subsequently added legislative delays to enforcement provisions. The practical effect is that health plans face no federal penalties for failing to complete or submit NQTL comparative analyses, even though the underlying parity requirement remains in effect. Advocacy groups and behavioral health providers have criticized the pause as a significant setback for parity enforcement.

Does the enforcement pause mean MHPAEA parity requirements no longer apply?

No. The enforcement pause applies specifically to the NQTL comparative analysis documentation and submission requirement from the 2024 final rule. The underlying MHPAEA parity requirements remain fully in effect. Plans that impose more restrictive prior authorization, higher cost-sharing, narrower networks, or more burdensome step therapy on behavioral health services compared to medical/surgical services are still violating federal law. The difference is that the specific mechanism requiring plans to proactively demonstrate compliance is not currently being enforced at the federal level.

Can behavioral health providers still file parity complaints?

Yes, and they should. Providers can file parity complaints through state insurance departments, the Department of Labor (for ERISA plans), CMS (for Medicaid managed care and CHIP plans), and state attorneys general. State-level enforcement has not been paused, and many states are increasing enforcement activity. Filing complaints creates documented evidence of violations that supports future enforcement regardless of the federal timeline. Every complaint that is not filed is a violation that goes unrecorded.

How much revenue are behavioral health providers losing due to parity gaps?

Actuarial analyses estimate parity violations cost the behavioral health system approximately $12 billion annually. For individual practices, the impact typically ranges from 8% to 15% of annual revenue through prior authorization denials (4% to 8% of claims), network adequacy gaps (limiting patient volume and forcing out-of-network utilization), and reimbursement rate differentials (10% to 30% lower per service compared to medical/surgical equivalents). A practice billing $2 million annually can expect $180,000 to $340,000 in parity-related revenue losses.

What should behavioral health providers do while enforcement is paused?

Focus on five actions: document every parity violation in a structured log, file state-level parity complaints for documented violations (especially in states with strong enforcement), track denial rates by service type to build data-driven evidence, use contract renegotiation to address parity gaps directly with payers, and engage with professional associations lobbying for enforcement resumption. The documentation you build during the pause will be essential when enforcement resumes.

Editorial Standards

Last reviewed: February 26, 2026

Methodology

• 2024 MHPAEA final rule (89 FR 77586) reviewed for NQTL comparative analysis requirements and enforcement provisions
• CMS and DOL enforcement guidance and press releases reviewed for enforcement pause timeline and scope
• Milliman and Bowman Family Foundation actuarial analyses reviewed for parity gap financial impact estimates
• State parity enforcement activity tracked through state insurance department enforcement actions and published reports

Primary Sources

• Federal Register: 2024 MHPAEA Final Rule (89 FR 77586)
• DOL MHPAEA Enforcement Page
• CMS MHPAEA Implementation Resources
• Milliman: Addiction and Mental Health vs. Physical Health Utilization Analysis
• The Kennedy Forum: Parity Tracking Resources