Mental Health Parity Pitfall to Avoid: Network Adequacy Data

Jenny Gartman, CEBSMarch 27, 2025March 27, 2025Post a Comment

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans that provide mental health or substance use disorder (MH/SUD) benefits to offer parity between coverage of physical health conditions and mental health conditions. The Department of Labor (DOL) Employee Benefits Security Administration (EBSA) enforces MHPAEA and reports annually to Congress on how agency investigators are working with plan sponsors and administrators to bring them into compliance.

Much of DOL’s 2024 MHPAEA report to Congress, issued January 17, 2025, focused on EBSA’s enforcement approach to nonquantitative treatment limitations (NQTLs) for network adequacy and network composition. Network-related EBSA investigations typically involve multiple interviews of plan officials and service provider representatives, claims data analysis and extensive document review.

What’s new: Part of the report is an unredacted 2024 settlement agreement between EBSA and a multiemployer health plan that describes the actions the plan agreed to undertake to correct alleged violations of MHPAEA regarding network composition and network adequacy. There are sample lists and a chart format of data to report on provider networks.

Why it matters: While the settlement agreement addresses the specific violation and facts of this case, the agreement illustrates the types of activities that other plans can implement to monitor and address disparities in access to providers.

Network Utilization, Access Standards and Reimbursement Rates

The following are learnings for group health plans and administrators from EBSA’s approach to investigating whether plans comply with parity between medical/surgical (M/S) and MH/SUD for NQTLs related to network adequacy and network composition.

EBSA found disparities in out-of-network utilization and other outcomesreflecting access to care.
- EBSA considers it a red flag when participants go out of network much more often for MH/SUD treatments than for medical/surgical M/S treatments.
- EBSA reviews out-of-network utilization data in all its cases investigating NQTLs related to network composition.
EBSA found disparities in access standards and processes for monitoring adequacy of networks.
- Many plans pointed to access standards as a large part of how they monitor and ensure network parity. These standards often took the form of:
  - Provider-to-member ratios (e.g., one provider to 2,000 members)
  - Time and distance standards (e.g., one provider within 15 minutes or 30 miles)
  - Maximum wait times (e.g., initial appointment within ten days, follow-up appointment within 20 days of initial appointment).
- EBSA found plans with standards that appear to require fewer MH/SUD providers in their network and may result in less access to MH/SUD treatment than to M/S treatment.
EBSA found disparities in network provider reimbursement rates and found that plans could not explain methodologies resulting in reimbursement rate disparities.
- Plans use reimbursement rates to encourage provider participation in a network. A plan or issuer can raise rates to increase the number of health care providers (or the proportion of health care providers) who are in-network in an area, which increases access to specific services, including MH/SUD services.

Adequacy of M/S and MH/SUD Networks

The report to Congress included a settlement agreement resulting from an EBSA investigation of the NQTL “standards for provider admission to participate in a network including reimbursement rates, for in-network inpatient and in-network outpatient services.” The settlement agreement exemplifies how plans, through their insurance network administrators, can monitor network adequacy standards and address network gaps. Data lists provide examples of how a plan can show that it uses the same or comparable standards to evaluate the adequacy of M/S and MH/SUD networks.

In the settlement agreement between EBSA and a multiemployer health fund, the fund neither admits nor denies the following alleged violations:

The fund, through its network administrator, uses different standards to evaluate the adequacy of its M/S and MH/SUD networks.
The fund, through its network administrator, does not respond comparably to identified deficiencies in its M/S and MH/SUD networks.
The fund’s own practices for addressing deficiencies in its network are not applied comparably to M/S and MH/SUD benefits.

Highlights From Section A, “Measurement and Improvement of the Network Administrator’s Network,” of the Settlement Agreement

The fund will take the following actions.

Define high-volume specialists as the top five categories of M/S specialists and the top five categories of MH/SUD specialists (as measured by claims volume) used by the fund’s participants and beneficiaries.
Define high-impact specialists by using the fund’s claims and cost data to identify the top five M/S and the top five MH/SUD specialists treating conditions that either have a high mortality/morbidity rate or require significant resources (i.e., cost of treatment exceeds $10,000).
Use the definitions of high-volume specialists and high-impact specialists in evaluating the network administrator’s network adequacy standards applied to M/S and MH/SUD specialists.

During an 18-month monitoring period, on a quarterly basis, the fund will evaluate the comparative adequacy of its network administrator’s network as applied to M/S and MH/SUD providers generally, as well as the adequacy of the network with respect to high-volume specialists and high-impact specialists in particular. The fund will identify any network gaps and will work with its network administrator to take affirmative, documented steps that are reasonably designed to close the gaps within the monitoring period.

In each quarterly review, the fund will collect and evaluate certain data and measurements to identify network gaps using six tables/lists of data elements. This blog will focus on Table 1, which shows the negotiated corrections for the fund’s disparate rate of out-of-network (OON) utilization for MH/SUD services as compared to M/S services.

Table 1, titled “Out-of-Network Utilization,” lists categories to track separately and includes a sample chart format showing headings that are merged cells, rows and columns. The major categories are:

Inpatient services vs. outpatient services
Mental health (MH) vs. substance use disorder (SUD) vs. medical/surgical
Professional vs. facility (and specific provider types within professional and facility).

Images from page 137 of “Report to Congress on MHPAEA Enforcement and Implementation, 2024.”

Note: The sample tables of data and chart format start on page 137 of the report.

The network categories to track separately are outlined in the settlement agreement (Attachment A) as follows. Notes about the outline:

We have spelled out acronyms that are not in the original.
The outpatient services and inpatient services are the same except for MH/SUD facilities (e) and (f) differ for outpatient and inpatient.

Outpatient services
1. Medical/surgical professional
  1. Primary care provider (PCP)/family practice
  2. Pediatrician
  3. OB/GYN
  4. All other specialty
2. Mental (MH) professional
  1. Psychiatrist (not including child/adolescent psychiatrists)
  2. Child/adolescent psychiatrist
  3. Psychologist (not including child/adolescent psychologists)
  4. Child/adolescent psychologists
  5. Physician board-certified in addiction medicine
  6. Behavioral health non-M.D. prescriber (e.g. behavioral health nurse practitioner (BHNP))
  7. All other
    1. Master’s-level providers
    2. Non-master’s-level professional providers
3. Substance use disorder (SUD) professional
  1. Psychiatrist (not including child/adolescent psychiatrists)
  2. Child/adolescent psychiatrist
  3. Psychologist (not including child/adolescent psychologists)
  4. Child/adolescent psychologists
  5. Physician board-certified in addiction medicine
  6. Behavioral health non-M.D. prescriber (e.g. behavioral health nurse practitioner (BHNP))
  7. All other
    1. Master’s-level providers
    2. Non-master’s-level professional providers
4. Medical/surgical facility
  1. Child/adolescent
  2. All other
5. MH outpatient facility
  1. Intensive outpatient program (IOP)
  2. Child/adolescent
  3. All other
6. SUD outpatient facility
  1. Intensive outpatient program (IOP)
  2. Child/adolescent
  3. All other
Inpatient services
1. Medical/surgical professional
  1. Primary care provider (PCP)/family practice
  2. Pediatrician
  3. OB/GYN
  4. All other specialty
2. Mental (MH) professional
  1. Psychiatrist (not including child/adolescent psychiatrists)
  2. Child/adolescent psychiatrist
  3. Psychologist (not including child/adolescent psychologists)
  4. Child/adolescent psychologists
  5. Physician board-certified in addiction medicine
  6. Behavioral health non-M.D. prescriber (e.g. behavioral health nurse practitioner (BHNP))
  7. All other
    1. Master’s-level providers
    2. Non-master’s-level professional providers
3. Substance use disorder (SUD) professional
  1. Psychiatrist (not including child/adolescent psychiatrists)
  2. Child/adolescent psychiatrist
  3. Psychologist (not including child/adolescent psychologists)
  4. Child/adolescent psychologists
  5. Physician board-certified in addiction medicine
  6. Behavioral health non-M.D. prescriber (e.g. behavioral health nurse practitioner (BHNP))
  7. All other
    1. Master’s-level providers
    2. Non-master’s-level professional providers
4. Medical/surgical facility
  1. Child/adolescent
  2. All other
5. MH inpatient facility
  1. Acute
  2. Partial hospitalization program (PHP)
  3. Residential
  4. Child/adolescent
6. SUD inpatient facility
  1. Acute
  2. Partial hospitalization program (PHP)
  3. Residential
  4. Child/adolescent
In-network claims (INN)
1. Total billed amount
2. Total allowed amount
3. Total paid amount
4. Total claim lines
Out-of-network claims (OON)
1. Total billed amount
2. Total allowed amount
3. Total paid amount
4. Total claim lines

Additional Data Lists

Stay tuned for a future blog that focuses on the other five data and measurement lists in section A, “Measurement and Improvement of the Network Administrator’s Network” of the settlement agreement, which are as follows:

Network providers actively submitting claims
Wait times for new and existing patients (based on participant/patient surveys)
Time and distance measurements
Provider-to-member ratios
Network retention/loss data to report.

Developed by International Foundation Information Center staff. This does not constitute legal advice. Please consult your plan professionals for legal advice.