Managed Care Outlook 2025

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Read time: 6 minutes

The long-awaited final rule for Mental Health Parity and Addiction Equity Act (MHPAEA) compliance came out earlier this year, bringing both good and bad news for those tasked with mental health parity compliance. While there is some relief that the Departments of Labor, Health and Human Services, and Treasury dropped the “mathematical test” for non-quantitative treatment limitations (NQTLs) after receiving over 10,000 comments, much uncertainty remains. Managed care organizations (MCOs) should already be ready to roll out their comparative analyses to meet the new 2025 “design and application” and other new requirements, but the requirements that go into effect in 2026 are going to take some time to implement. Below, we suggest steps to take in 2025 to prepare for those requirements.

What’s in store for 2026?

MCOs should use 2025 to address the more challenging parts of the new rule, including the meaningful benefits standard, the prohibition on discriminatory factors and evidentiary standards, the relevant data evaluation requirements and the related outcome-focused requirements in the new rule’s comparative analysis provisions. These changes apply from the first day of the first plan year beginning on or after January 1, 2026.

Meaningful benefits. While the final rule maintains that MHPAEA is not a benefits mandate, the new rule states that plans and issuers must provide at least one “core treatment” for each covered condition in a relevant benefits classification where medical/surgical benefits are offered, to meet the “meaningful benefit” requirement under the new rule. Core treatment is defined as “standard treatment or course of treatment, therapy, service or intervention indicated by generally recognized independent standards of current medical practice.”

Takeaways:

  • Review plan benefits to determine if the plan offers a “core treatment” for covered conditions. For example, ABA therapy for autism spectrum disorder and coverage of nutritional counseling for eating disorders are specified as core treatments. Plans also need to cover medications for opioid use disorder if they cover substance use disorder.
  • From the “core treatment” language in the final rule, we understand that services like wilderness therapy are not required to be covered because residential treatment qualifies as core treatment for mental health in the intermediate classification of benefits.

Prohibition on discriminatory factors. As part of the new design and application requirements for comparative analyses, the new rule prohibits plans and MCOs from using discriminatory factors and evidentiary standards in designing NQTLs that apply to mental health benefits. Under the new rule, a factor or evidentiary standard is discriminatory if the information or sources on which it is based are biased or not objective in a manner that discriminates against mental health benefits as compared to medical/surgical benefits.

Takeaways:

  • Consider whether the information and sources they use are based on independent professional medical or clinical standards, which the new rule considers unbiased and objective.
  • Prepare for challenges to medical necessity criteria from private companies, as opposed to criteria developed by independent community organizations.
Key takeaways
  • Ensure coverage of core mental health treatments based on independent standards
  • Use unbiased and objective factors and evidence to justify limits on mental health benefits
  • Collect and evaluate data on NQTLs impact on access and outcomes and address disparities
  • Prepare for fiduciary certification and quick response to comparative analysis requests
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