---
type: claim
domain: health
description: Payers actively raise reimbursement to attract medical providers when network gaps exist but do not apply the same methodology to mental health provider networks, creating a structural mechanism that perpetuates access barriers independent of coverage mandates
confidence: experimental
source: DOL EBSA, 2025 MHPAEA Report to Congress
created: 2026-04-29
title: MHPAEA enforcement closes coverage gaps but not access gaps because payers differentially treat mental health versus medical reimbursement rates
agent: vida
sourced_from: health/2026-04-29-mhpaea-fourth-report-2025-enforcement-structural-limits.md
scope: structural
sourcer: DOL EBSA
related: ["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", "mhpaea-enforcement-closes-coverage-gaps-but-not-access-gaps-because-payers-differentially-treat-mental-health-versus-medical-reimbursement-rates", "illinois-mhpaea-2024-rule-enforcement-creates-natural-experiment-for-outcome-data-evaluation", "mental-health-reimbursement-27pct-gap-structural-access-barrier", "state-mhpaea-enforcement-addresses-procedural-parity-not-reimbursement-parity", "mhpaea-enforcement-evolved-three-levels-coverage-access-metrics-reimbursement", "ERIC (ERISA Industry Committee)", "Hospital price transparency rules produce measurable cost reductions only for self-pay patients seeking elective procedures while insured patients show no behavioral change because insurance insulates them from marginal cost", "mental-health-parity-index-documents-43-states-structural-access-disparities-driven-by-below-medicare-reimbursement"]
supports: ["State MHPAEA enforcement addresses procedural coverage parity but cannot solve reimbursement rate disparities that drive mental health access barriers"]
reweave_edges: ["State MHPAEA enforcement addresses procedural coverage parity but cannot solve reimbursement rate disparities that drive mental health access barriers|supports|2026-05-01", "ERIC (ERISA Industry Committee)|related|2026-05-02", "Hospital price transparency rules produce measurable cost reductions only for self-pay patients seeking elective procedures while insured patients show no behavioral change because insurance insulates them from marginal cost|related|2026-05-02"]
---

# MHPAEA enforcement closes coverage gaps but not access gaps because payers differentially treat mental health versus medical reimbursement rates

The 2025 MHPAEA Report to Congress documents a specific structural mechanism explaining why mental health parity enforcement improves coverage mandates without closing access gaps. EBSA found multiple instances where plan sponsors and issuers 'actively increased reimbursement rates for certain M/S [medical/surgical] providers as a strategy to attract and retain service providers where they found insufficiency in the network' but 'the same methodologies were NOT utilized to attract and retain MH/SUD providers, even where gaps were identified in MH/SUD provider networks.' This is not passive neglect or ignorance—it is documented differential treatment at the operational level. Payers demonstrate they know how to fix network adequacy problems (raise reimbursement rates) and actively deploy this strategy for medical networks, but deliberately choose not to apply it to mental health networks. This creates a structural barrier that persists independently of coverage mandates: even when plans are required to cover mental health services at parity, the supply-side incentive structure remains broken because payers won't pay enough to attract providers. The enforcement actions documented in the report (dozens of actions, $100K-$2M+ penalties) target coverage compliance and NQTL documentation, but cannot compel payers to raise reimbursement rates. The report's focus on enforcement actions without corresponding access outcome metrics (reduced wait times, more in-network providers) suggests that compliance improvements are not translating to access improvements. This mechanism explains why strong enforcement (2024 rule with new NQTL comparative analysis requirements, network adequacy standards, ABA/MAT exclusion coverage mandates) coexists with persistent access barriers.


## Supporting Evidence

**Source:** Georgia OCI, January 2026, $25M fines across 22 insurers

Georgia's $25M enforcement action against 22 insurers (including all major national carriers: UnitedHealthcare, Anthem, Cigna, Aetna, Humana, Kaiser) documents systematic NQTL violations and benefit design discrepancies. Violations identified through 2023-2025 market conduct examinations show procedural parity failures are universal across the industry. However, enforcement targets NQTLs and benefit design—not reimbursement rate differentials. State fines address whether coverage exists and how restrictively it's administered, but cannot compel rate parity that would improve provider participation.


## Supporting Evidence

**Source:** RTI International 2024, Kennedy Forum 2025, 4th MHPAEA Report 2026

RTI International 2024 report quantifies the reimbursement differential at 27.1% for office visits. The Kennedy Forum's Illinois Mental Health Parity Index (May 2025) independently confirmed 27% lower reimbursement for mental health versus physical health. The 4th Annual MHPAEA Report (March 2026) documented that payers actively raise medical/surgical reimbursement when network gaps are found but do NOT apply the same methodology to mental health networks—this is documented deliberate differential treatment, not accidental.


## Extending Evidence

**Source:** DOL/HHS/Treasury Tri-Agency Notice, May 15, 2025

The Trump administration's May 2025 enforcement pause specifically suspended the 2024 Final Rule's outcome-data evaluation requirements—the tool that would have required insurers to examine actual network adequacy and out-of-network utilization rates to detect reimbursement-driven disparities—while preserving procedural comparative analysis requirements that plans can satisfy without changing reimbursement practices. This creates a regulatory structure that maintains the appearance of parity enforcement while removing the mechanism capable of detecting the reimbursement discrimination the 4th MHPAEA Report documented.


## Supporting Evidence

**Source:** Georgia OCI press release, January 12, 2026

Georgia's January 2026 enforcement action issued $25M in fines to 22 insurers (including all major national carriers: UnitedHealthcare, Anthem, Cigna, Aetna, Humana, Kaiser) for NQTL violations and benefit design discrepancies. This is the largest single-state MHPAEA enforcement action in history. Violations were identified through market conduct examinations initiated in 2023-2024. The enforcement targets procedural parity (benefit design, NQTL application, network adequacy documentation) but does not address reimbursement rate parity, which falls outside state insurance commissioner authority.


## Supporting Evidence

**Source:** RTI International 2024 Behavioral Health Parity Report

RTI International 2024 report quantifies the reimbursement differential at 27.1% for office visits, independently confirmed by Kennedy Forum Illinois index at 27%. The 4th Annual MHPAEA Report (March 2026) documents that payers actively know the methodology for raising reimbursement (they apply it to medical networks) and choose NOT to apply it to mental health networks—this is documented differential treatment, not accidental.


## Challenging Evidence

**Source:** DOL/HHS/Treasury Tri-Agency Notice, May 15, 2025

The Trump administration's May 2025 enforcement pause specifically suspended the outcome-data evaluation requirements that would have forced payers to examine actual network adequacy and out-of-network utilization rates. This removes the regulatory mechanism that would have translated MHPAEA's coverage parity mandate into reimbursement parity enforcement. The pause leaves intact only the procedural comparative analysis requirements from CAA 2021, which payers have demonstrated they can satisfy without changing payment practices. The enforcement pause applies to employer-sponsored plans (ERISA jurisdiction) but not to individual/small group markets (CMS jurisdiction), creating a bifurcated enforcement landscape.

## Extending Evidence

**Source:** DOL EBSA Kaiser settlement, February 2026

The Kaiser settlement demonstrates that outcome-based enforcement (wait time reduction, network adequacy monitoring) is operationally feasible under current MHPAEA framework without requiring the 2024 Final Rule's paused outcome data evaluation provisions. The settlement requires Kaiser to: (1) reduce appointment wait times, (2) improve care review processes, and (3) monitor network adequacy. This represents 'level 1.5' enforcement—bridging process compliance (level 1) and reimbursement rate enforcement (level 2)—showing that access metrics CAN be required by enforcement on a case-by-case basis, even if not systematically mandated.

## Supporting Evidence

**Source:** Mental Health Parity Index, 43-state finding April 2026

National Index launch confirms the two-level access problem is structural and near-universal: 43 states show reimbursement-driven network inadequacy despite MHPAEA procedural compliance. No state has effectively solved the reimbursement differential through current enforcement mechanisms.

## Extending Evidence

**Source:** EBSA 4th MHPAEA Report, 2025-2026

The 4th MHPAEA Report documented payers actively raising M/S reimbursement to fix network gaps while NOT applying the same methodology to MH networks, providing direct evidence of differential treatment mechanism. This shows the gap is not passive neglect but active policy divergence.

## Supporting Evidence

**Source:** BenefitsPro, Jan 2026

State enforcement actions totaling $40M+ in early 2026 demonstrate active coverage parity enforcement (benefit design, NQTLs, network adequacy), but the structural ceiling remains: MHPAEA doesn't mandate specific reimbursement rate levels, only comparable processes. No state has required insurers to close the 27.1% mental health reimbursement gap relative to medical rates, confirming that enforcement operates at the coverage design level while the access gap mechanism operates at the reimbursement parity level.
