Tri-Agencies Release Fourth Mental Health Parity Report to Congress

On March 3, 2026, the Department of Labor (DOL), Department of Health and Human Services (HHS), and Department of the Treasury (TREAS) — collectively, the “Tri-Agencies” — published their fourth annual report to Congress on enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). The 2025 Report demonstrates a shift in approach by the Tri-Agencies in its tone and content and suggests that federal regulators, and the DOL in particular, are not as active as they previously were in MHPAEA enforcement. However, federal enforcement remains ongoing, and state enforcement of mental health parity laws continues to grow. Plans and issuers must continue to maintain comprehensive compliance processes and documentation for MHPAEA compliance.

Background

The 2025 Report is made to Congress in accordance with the mandate set forth in the 2021 Consolidated Appropriations Act (CAA), which requires the Tri-Agencies to submit a report to Congress summarizing their efforts over the prior year to collect comparative analyses from plans and issuers as well as any findings made with respect to noncompliance with MHPAEA. The last report to Congress (the 2024 Report) was published on January 23, 2025, on the final working day of the Biden Administration, covering a reporting period ending in July 2023.

The 2025 Report covers two years of enforcement activity by the DOL, through the Employee Benefits and Security Administration (EBSA); and by HHS, through the Centers for Medicare and Medicaid Services (CMS), ranging from August 1, 2023, through July 31, 2025. Notably, the 2025 Report comes nearly a year after the Administration paused enforcement of the 2024 final regulations on MHPAEA.

Key Statistics

• • 85 initial letters requesting comparative analyses.
  • 76 insufficiency letters.
  • 34 initial determination letters.
  • 15 final determinations of noncompliance.

2025 MHPAEA Report Findings

Common Areas of Noncompliance

The 2025 Report underscores the following recurring problem areas for health plans and issuers:

• • Prior Authorization and Utilization Review: More stringent requirements or shorter authorization periods for mental health and substance use disorder (MH/SUD) services than for comparable medical/surgical care.
  • Network Adequacy: Insufficient numbers of in-network MH/SUD providers, resulting in access barriers.
  • NQTL Documentation: The Tri-Agencies determined that plans and issuers did not provide adequate comparative analyses to demonstrate Nonquantitative Treatment Limitation (NQTL) compliance, failing to sufficiently detail both the design and application of NQTLs.

EBSA

EBSA’s enforcement activity appeared to reflect a targeted approach to ensuring compliance — with a focus on NQTLs most affecting access to care — and suggested a willingness to resolve concerns through corrective action plans where plans demonstrated sufficient remediation. 

In the 2025 Report, EBSA noted a marked decrease in insufficiency letters issued and recognized that many plans and issuers removed limitations or exclusions prior to EBSA’s findings of insufficiency. EBSA indicated that its focus is on the NQTLs with the “most significant impact on access to care,” including network adequacy and exclusions of key treatments for MH/SUD conditions (e.g., exclusions of applied behavior analysis (ABA) therapy for autism spectrum disorder, nutritional counseling for eating disorders, and medication-assisted treatment for opioid use disorder). This is reflected in the NQTLs requested by EBSA during the reporting period, although the initial determinations issued also reflect a notable focus on prior authorization and out-of-network provider reimbursement.

EBSA issued five final determinations of noncompliance to four plans, all involving prior authorization. The final determinations for one plan involved prior authorization, concurrent review, network adequacy, and in-network and out-of-network reimbursement. EBSA did issue substantially more initial determination letters than final determination letters and specifically noted that, in some instances, the corrective action plans submitted by plans in response to initial determinations of noncompliance were to resolve EBSA’s concerns.

EBSA also cautioned against the use of consultants unfamiliar with plan operations when completing comparative analyses. It specifically reminded self-funded plans that responsibility for MHPAEA compliance lies with the plan rather than any third-party administrator or other service provider. 

CMS

Despite operating with a narrower enforcement scope than EBSA, CMS engaged in comparatively robust enforcement activity during the reporting period.

CMS requested a similar number of NQTL comparative analyses to EBSA. Interestingly, given that CMS’ scope is narrower with respect to MHPAEA enforcement, CMS issued more than four times as many insufficiency letters as EBSA (62 as compared to 14) and twice as many final determination letters as EBSA (10 as compared to five), although notably fewer initial determination letters. The comparative analyses requested by CMS are largely utilization management NQTLs, although CMS also requested comparative analyses on network admission, provider reimbursement, and treatment limitations.

CMS continues to focus closely on the content and sufficiency of NQTL comparative analyses, emphasizing that plans must clearly demonstrate how their processes, factors, and evidentiary standards are applied equally to both MH/SUD and medical/surgical benefits. CMS determined that most plans failed to provide enough detail, at least in their initial submissions, to substantiate parity.

In its final determinations, CMS found that several plans imposed more restrictive concurrent review and prior authorization criteria on MH/SUD benefits than on medical/surgical benefits. For example, mental health inpatient services were often subject to more frequent or intensive utilization reviews, earlier or repeated initial reviews, and shorter authorization periods than comparable medical/surgical services. These findings led CMS to mandate corrective actions, requiring plans to align their review criteria and in some cases remediate claims.

Takeaways for Health Plans and Issuers

The 2025 Report, which is the first report released by the Trump Administration, suggests that the Tri-Agencies may be rethinking their approach to enforcement and are still evaluating whether to retain the 2024 parity regulations.

The 2025 Report is noticeably different from previous reports to Congress in length (32 pages as compared to 142 pages for the 2024 Report) and content. The 2025 Report provides detail on the comparative analyses requested, final determinations issued, and types of issues identified, as required by statute. However, it covers these topics more briefly than in previous reports and does not expound on other topics. There is also little discussion of enforcement priorities and no requests for additional enforcement authorities. Without explicitly asking for more funding, EBSA does note that the supplemental funding from the CAA to support its enforcement work ended in December 2024.

Further, the Tri-Agencies take a markedly different tone in the 2025 Report. The 2025 Report mentions the “numerous challenges” that MHPAEA has caused employers and plan sponsors and acknowledges that these challenges can negatively impact access to care. The Tri-Agencies indicate that they are “committed to ensuring individuals receive protections under the law in a way that is not unduly burdensome for plans and issuers” and recognize the “complex and careful balance” between access to care, high costs, and fraud, waste, and abuse efforts. The Tri-Agencies also reiterate that they are reconsidering the 2024 rules and undertaking a broader reexamination of their enforcement approach.

Even if the tenor of federal enforcement is shifted, federal enforcement remains ongoing, particularly by CMS. Further, though not addressed in the report, state enforcement of mental health parity continues to escalate. The standards and expectations imposed by state regulators can be significant, and requests from state regulators are often expansive. States also have numerous enforcement mechanisms to address health plan noncompliance, including through the imposition of extensive monetary penalties. Plans would be wise to continue dedicating compliance resources, developing robust documentation in this area, and making proactive adjustments to plan design and administration. 

We encourage plans, issuers, and employers seeking guidance on MHPAEA compliance (and state analogues) to reach out to any author of this alert or to their preferred Crowell & Moring lawyer.  We are happy to assist with counseling in this area, including developing robust NQTL comparative analyses, responding to agency inquiries, or proactively assessing plan design.