Mental health parity: how to appeal when coverage is more restrictive than medical care
The Mental Health Parity and Addiction Equity Act bans plans from imposing tougher limits on mental health than on medical care. Here is how to use parity in your appeal.
What parity requires
MHPAEA (the Mental Health Parity and Addiction Equity Act of 2008) bans group health plans from applying treatment limits to mental health and substance use disorder benefits that are more restrictive than the limits on medical and surgical benefits.
Quantitative limits (visit caps, dollar caps, copays) and non-quantitative limits (medical necessity criteria, step therapy, prior authorization standards) must be at parity.
Source: 29 CFR 2590.712 and the 2024 final rule strengthening NQTL analysis. See https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-parity.
Common parity violations to flag in an appeal
Residential treatment for mental health denied while skilled nursing for medical conditions is approved on similar criteria.
Stricter prior-auth criteria for inpatient mental health than for inpatient medical admissions.
Step therapy for SUD medications (buprenorphine, naltrexone) when no comparable step therapy applies to comparable medical drugs.
Lower visit caps for psychotherapy than for physical therapy.
How to invoke parity in the appeal letter
Cite MHPAEA and 29 CFR 2590.712 by name. Identify the specific limit that appears more restrictive than the comparable medical limit.
Request the plan's comparative analysis under MHPAEA — plans must produce a written analysis of any non-quantitative treatment limit on request.
If the plan refuses or the analysis is deficient, complain to the U.S. Department of Labor Employee Benefits Security Administration (askEBSA at 1-866-444-3272) or your state insurance department.
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Does parity apply to autism, ABA, or eating disorders?+
MHPAEA applies to all mental health and substance use disorder benefits the plan offers. If the plan covers ABA or eating disorder treatment, parity governs the limits. Whether a plan must offer the benefit at all is a separate ACA essential health benefit question.
Does parity apply to Medicare?+
Original Medicare and Medicare Advantage are not subject to MHPAEA, but CMS has rules requiring parity-like treatment in Part C. Medicaid managed care is subject to a parity rule at 42 CFR 438.910.
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills