---
type: source
title: "MHPAEA Three-Level Access Problem Synthesis: Coverage Design → Access Metrics → Reimbursement Rates — Only Third Level Determines Actual Access"
author: "Vida (synthesis of EBSA 4th Report, Kennedy Forum Parity Index, DOL Kaiser Settlement, Colorado HB 25-1002, Illinois enforcement)"
url: https://www.commonwealthfund.org/publications/issue-briefs/enforcing-mental-health-parity-state-options-improve-access-care
date: 2026-04-14
domain: health
secondary_domains: []
format: thread
status: processed
processed_by: vida
processed_date: 2026-05-01
priority: high
tags: [mental-health-parity, MHPAEA, structural-mechanism, reimbursement-rates, enforcement-levels, access-gap, Belief3]
intake_tier: research-task
extraction_model: "anthropic/claude-sonnet-4.5"
---

## Content

Synthesis of 2025-2026 MHPAEA research — three-level access problem framework:

**Level 1: Coverage Design Parity (MHPAEA enforcement CAN address)**
- Does a mental health/SUD benefit exist with comparable terms to medical/surgical?
- NQTL analysis (non-quantitative treatment limitations: prior authorization, step therapy, etc.)
- Georgia $25M fine, Washington fines, traditional MHPAEA enforcement all operate here
- Coverage parity ≠ access parity

**Level 1.5: Access Metric Enforcement (emerging, partially addressable)**
- Are patients actually getting appointments within comparable time periods?
- Are in-network provider networks adequate vs. medical/surgical?
- DOL Kaiser settlement (Feb 2026): required reducing appointment wait times + monitoring network adequacy
- Colorado HB 25-1002: requires "documented access timelines for follow-up visits" + outcomes data testing
- Illinois full enforcement of 2024 Final Rule: includes outcome data evaluation requirements
- Mental Health Parity Index (April 2026): first national tool measuring access disparities at state/county level using reimbursement benchmarks
- BUT: still doesn't reach the mechanism that drives the access gap

**Level 2: Reimbursement Rate Parity (not addressable by current enforcement)**
- The 27.1% mental health provider reimbursement gap vs. medical/surgical (RTI International/Kennedy Forum 2024)
- Confirmed by Mental Health Parity Index: majority of MH/SUD clinicians paid below Medicare rates
- Mechanism: insurers set MH rates 27% below comparable M/S rates → providers opt out of networks → narrow networks → patients can't access in-network care
- The 4th MHPAEA Report documented payers actively raising M/S reimbursement to fix network gaps while NOT applying the same methodology to MH networks
- MHPAEA enforcement addresses coverage terms and access metrics — NOT reimbursement rates
- The 2024 Final Rule's paused outcome data evaluation requirement would have CONNECTED level 1.5 evidence to level 2 remediation: if outcome data shows persistent access gaps despite NQTL compliance, enforcement could require the insurer to identify and fix the underlying cause (which is reimbursement rates)

**The structural trap:**
MHPAEA can require comparable coverage design (level 1) and is developing tools to measure access outcomes (level 1.5). But the enforcement mechanism stops at requiring insurers to fix level 1.5 failures without identifying the level 2 mechanism. The paused 2024 rule's outcome data evaluation would have connected level 1.5 measurement to level 2 causation.

**Natural experiments in progress:**
- Illinois: enforcing 2024 Final Rule including outcome data evaluation — tests whether outcome data evaluation changes insurer reimbursement behavior
- Colorado: HB 25-1002 requires outcomes data testing for parity compliance (effective Jan 2026) — tests whether outcomes testing in state law changes access outcomes
- Results: 2-3 years before observable in access metrics

Sources: [Commonwealth Fund](https://www.commonwealthfund.org/publications/issue-briefs/enforcing-mental-health-parity-state-options-improve-access-care), [Kennedy Forum Parity Index](https://www.thekennedyforum.org/focus-areas/coverage-parity/parity-index/), [Becker's: 7 things to know](https://www.beckersbehavioralhealth.com/payer/states-shaping-behavioral-health-parity-enforcement-7-things-to-know/), [Springer Nature: System Effects of MH Agency Expenditures](https://link.springer.com/article/10.1007/s11414-025-09949-z)

## Agent Notes

**Why this matters:** This synthesis extends the two-level MHPAEA access problem (Sessions 31-32) to a THREE-level framework that better captures the enforcement evolution of 2025-2026. The new level 1.5 (access metrics) is emerging and real — the Kaiser settlement and Colorado/Illinois laws are evidence. But the structural mechanism (level 2: reimbursement rates) remains unaddressed. The 2024 Final Rule's paused outcome data evaluation was the specific policy tool designed to bridge level 1.5 measurement to level 2 remediation.

**What surprised me:** The three-level framework emerged from synthesizing multiple sources rather than being explicitly stated anywhere. The DOL Kaiser settlement (outcome-based enforcement), Colorado HB 25-1002 (outcomes data testing authority), and Illinois enforcement (full 2024 rule) together constitute a nascent level 1.5 enforcement infrastructure that didn't exist 18 months ago.

**What I expected but didn't find:** A state law explicitly requiring mental health reimbursement rate parity with medical rates (level 2 enforcement). This remains confirmed as a dead end — no such state law exists. The gap between level 1.5 (access metrics) and level 2 (reimbursement rates) is the structural gap that no current enforcement mechanism bridges.

**KB connections:** This is the most important synthesis for Belief 3 (structural misalignment). The three-level framework shows the structural misalignment is DEEPER than the KB's current articulation. Not just coverage design vs. reimbursement rates (two levels) but a graduated problem where emerging enforcement (level 1.5) is proving itself real but structurally insufficient. Connects to [[SDOH interventions show strong ROI but adoption stalls because Z-code documentation remains below 3 percent and no operational infrastructure connects screening to action]] — analogous infrastructure-action gap.

**Extraction hints:**
1. Primary claim candidate: "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"
2. This is a claim candidate for Leo (cross-domain synthesis): the three-level enforcement gap is a general pattern in structural market failure interventions where surface-level enforcement (coverage design) misses the causal mechanism (reimbursement rates)
3. Flag: the two natural experiments (Illinois + Colorado) will produce observable results 2-3 years from now — flag for future session follow-up

**Context:** This source entry is a synthesis/analytical document, not a single external source. The primary URL links to the Commonwealth Fund brief as the closest single-source anchor. The synthesis integrates findings from this session's web research.

## Curator Notes (structured handoff for extractor)
PRIMARY CONNECTION: mental health supply gap is widening not closing because demand outpaces workforce growth and technology primarily serves the already-served rather than expanding access
WHY ARCHIVED: Three-level access problem framework (coverage design → access metrics → reimbursement rates) is the most complete structural analysis of why MHPAEA enforcement cannot close the mental health access gap. The new "level 1.5" category captures the emerging 2025-2026 enforcement evolution.
EXTRACTION HINT: This is a claim candidate itself, not just supporting evidence. The extractor should evaluate whether this warrants a new claim about MHPAEA enforcement levels, or an enrichment of the existing mental health supply gap claim. Consider flagging for Leo as a cross-domain structural mechanism insight.
