The DOL, Treasury, and HHS (the departments) recently released the 2025 MHPAEA Report to Congress (the 2025 Report), summarizing enforcement efforts and key findings on the CAA 2021 nonquantitative treatment limitation (NQTL) comparative analysis requirement.
Background
The CAA 2021 amendments to MHPAEA require plans and insurers to prepare and document a comparative analysis of the design and application of NQTLs (e.g., prior authorization requirements and treatment exclusions). The analysis must show that NQTLs affecting mental health/substance use disorder (MH/SUD) benefits are no more restrictive than those affecting medical/surgical (MED/SURG) benefits. The departments also must report annually to Congress on related enforcement; the 2025 Report covers the period from August 1, 2023, through July 31, 2025 (the reporting period).
DOL Enforcement Activity
The DOL’s Employee Benefits Security Administration enforces MHPAEA for private employer-sponsored group health plans. The 2025 Report notes that recent NQTL enforcement emphasized access to MH/SUD care.
During the reporting period, the DOL issued 42 letters (30 to plans and 12 to insurers) requesting comparative analyses for 77 NQTLs. These requests most often involved provider network admission standards (which may affect network adequacy and access to in-network MH/SUD care). Other focus areas included exclusions for speech/occupational therapy, nutritional counseling, and residential care, as well as limits or exclusions for autism therapies.
As in prior reporting periods, the DOL found that many initial comparative analyses were deficient or incomplete (particularly for plans with carveout arrangements), and allowed plans and insurers the opportunity to supplement or cure the submissions. The DOL ultimately issued 25 initial noncompliance determinations for 43 NQTLs and five final noncompliance determinations for seven NQTLs, which is an increase from the prior reporting period.
Overall, the DOL reported corrective actions affecting more than 18 million participants across more than 39,000 plans. The corrections resulted in expanded access to opioid use disorder treatment, fewer barriers to autism spectrum disorder (ASD) therapies, improved access to nutritional counseling for eating disorders, and reduced preauthorization and concurrent review requirements for MH/SUD services.
To maximize impact, the DOL often sought to address corrections at the service provider level. For example, after identifying a TPA administering self-insured plans that improperly excluded applied behavior analysis (ABA) therapy for ASD, the DOL worked with the TPA to remove the exclusion from template documents, notify 97 affected plans, and reprocess 1,407 denied ABA claims totaling more than $1.05 million. The 2025 Report includes numerous additional examples of corrections addressing various NQTL deficiencies.
CMS Enforcement Activity
HHS’s Centers for Medicare and Medicaid Services (CMS) enforces MHPAEA for nonfederal governmental group health plans and insurers in certain states.
During the reporting period, CMS issued 43 letters (33 to plans and 10 to insurers) requesting comparative analyses for 43 NQTLs, most often involving prior authorization and medical necessity treatment limitations. Like the DOL, CMS reported that no analyses were sufficient at first submission and provided multiple opportunities to address deficiencies. CMS issued nine initial determination letters finding MHPAEA NQTL violations and 10 final determination letters of noncompliance, primarily regarding prior authorization and concurrent review requirements.
Employer Takeaway
MHPAEA compliance remains a top regulatory focus, as noted in our prior article on 2026 DOL enforcement priorities. Employers can expect continued scrutiny of MH/SUD coverage and common access barriers, including treatment exclusions, inaccurate provider directories, overly restrictive limits, and burdensome claims and appeals processes.
At the same time, the departments indicate that change may be coming. In the 2025 Report preface, the departments acknowledge that MHPAEA compliance has been challenging for many employers and that enforcement has sometimes complicated good-faith compliance efforts. They also state that enforcement should balance participants’ access to care with a plan’s ability to use NQTLs to manage costs and address waste, fraud, and abuse. The departments are reexamining their MHPAEA enforcement approach, including the CAA 2021 comparative analysis requirements.
As discussed in our recent update on MHPAEA regulations, the departments also intend to replace the 2024 MHPAEA final rule. That rule was generally not well received by employers and has not been enforced due to litigation challenging its validity. The departments intend to release the revised rule, which is expected to address the comparative analysis requirements, before year-end.
Meanwhile, the CAA 2021 NQTL comparative analysis requirement remains in effect. Employers should work with their carrier or TPA to ensure a detailed written analysis can be provided to a regulator or participant upon request and consider whether any changes are necessary in light of the common deficiencies cited in the 2025 Report. Employers should also confirm that day-to-day administration aligns with the plan document and analysis, and that participant complaints are addressed promptly.
NFP will continue to report on new guidance and related updates in Compliance Corner.
Read the full 2025 MHPAEA Report to Congress.