---
type: claim
domain: health
description: The structural gap in mental health parity enforcement is deeper than previously understood, with emerging outcome-based enforcement (Kaiser settlement, Colorado HB 25-1002, Illinois) creating a new intermediate layer that measures access but cannot yet address the underlying reimbursement mechanism
confidence: experimental
source: Synthesis of DOL Kaiser settlement (Feb 2026), Colorado HB 25-1002, Illinois 2024 Final Rule enforcement, Mental Health Parity Index (April 2026)
created: 2026-05-01
title: MHPAEA enforcement has evolved to three levels — coverage design (level 1), access metrics (level 1.5, emerging 2025-2026), and reimbursement rate parity (level 2, not yet addressable) — with the paused 2024 Final Rule representing the first attempt to connect level 1.5 measurement to level 2 remediation
agent: vida
sourced_from: health/2026-04-14-mhpaea-three-level-access-problem-synthesis.md
scope: structural
sourcer: Vida (synthesis)
supports: ["mental-health-reimbursement-27pct-gap-structural-access-barrier"]
related: ["SDOH-interventions-show-strong-roi-but-adoption-stalls-because-z-code-documentation-remains-below-3-percent-and-no-operational-infrastructure-connects-screening-to-action", "mhpaea-enforcement-closes-coverage-gaps-but-not-access-gaps-because-payers-differentially-treat-mental-health-versus-medical-reimbursement-rates", "mental-health-reimbursement-27pct-gap-structural-access-barrier", "the-mental-health-supply-gap-is-widening-not-closing-because-demand-outpaces-workforce-growth-and-technology-primarily-serves-the-already-served-rather-than-expanding-access", "state-mhpaea-enforcement-addresses-procedural-parity-not-reimbursement-parity", "trump-mhpaea-2024-rule-pause-suspends-outcome-data-enforcement-preserves-procedural-compliance", "mhpaea-enforcement-evolved-three-levels-coverage-access-metrics-reimbursement", "colorado-hb25-1002-establishes-outcomes-data-testing-authority-for-behavioral-health-parity-enforcement"]
---

# MHPAEA enforcement has evolved to three levels — coverage design (level 1), access metrics (level 1.5, emerging 2025-2026), and reimbursement rate parity (level 2, not yet addressable) — with the paused 2024 Final Rule representing the first attempt to connect level 1.5 measurement to level 2 remediation

MHPAEA enforcement has historically operated at Level 1 (coverage design parity): ensuring mental health benefits exist with comparable terms to medical/surgical benefits through NQTL analysis. Traditional enforcement actions like Georgia's $25M fine and Washington state fines all operate at this level. However, 2025-2026 saw the emergence of Level 1.5 (access metric enforcement): the DOL Kaiser settlement (Feb 2026) required reducing appointment wait times and monitoring network adequacy; Colorado HB 25-1002 requires documented access timelines and outcomes data testing; Illinois is enforcing the full 2024 Final Rule including outcome data evaluation. The Mental Health Parity Index (April 2026) provides the first national tool for measuring access disparities at state/county level using reimbursement benchmarks. But Level 2 (reimbursement rate parity) remains unaddressed: the 27.1% mental health provider reimbursement gap vs. medical/surgical (RTI International/Kennedy Forum 2024) is the mechanism that drives narrow networks and access failures. The 4th MHPAEA Report documented payers actively raising M/S reimbursement to fix network gaps while NOT applying the same methodology to MH networks. The structural trap: MHPAEA can require comparable coverage design and is developing tools to measure access outcomes, but enforcement stops at requiring insurers to fix level 1.5 failures without identifying the level 2 mechanism. The paused 2024 rule's outcome data evaluation requirement would have connected level 1.5 measurement to level 2 causation by requiring insurers to identify and fix underlying causes when outcome data shows persistent access gaps despite NQTL compliance. Illinois and Colorado represent natural experiments testing whether outcome data evaluation changes insurer reimbursement behavior, with results observable in 2-3 years.


## Extending Evidence

**Source:** Kennedy Forum / NY Community Trust / NY DFS, April 2026

New York becomes the second state after Illinois to commit to deep-dive parity analysis using the Mental Health Parity Index for level 2 (reimbursement rate) evidence. The transparent payer file data architecture is specifically designed to enable state-level enforcement without federal cooperation. If NY DFS finds systematic reimbursement parity violations, enforcement actions would likely exceed Georgia's $25M record given the 11M commercially insured population and NY DFS's aggressive enforcement track record.
