The Mental Health Parity and Addiction Equity Act (MHPAEA), passed in 2008, is the federal rule that stops a health plan from making therapy harder to get than a comparable medical service. Parity does not force a plan to cover every treatment. It requires that when a plan covers mental health and substance use care, the copays, deductibles, visit limits, prior authorization and network rules for that care are no stricter than the rules for medical and surgical care in the same category.
Adults under 65 with job-based, Marketplace, or Medicaid coverage are the audience for this guide, which explains which plans parity covers, what a visit limit or medical necessity denial looks like when it breaks the rule, and the step-by-step appeal path. Federal enforcement is in flux as of November 2026, so the page separates what is settled law from what regulators may change before the end of 2026.
Coverage Breakdown
Direct answer: do plans have to cover therapy at parity?
Yes. Federal parity law says a health plan that covers mental health care cannot apply stricter cost sharing, visit limits, or approval rules to therapy than it applies to comparable medical care. Marketplace and small-group plans must also cover mental health as an essential health benefit. If your plan denies therapy under a stricter rule, you can appeal, request independent external review, and file a parity complaint.
What parity requires: financial limits, visit limits, and nonquantitative rules (2026-2027)
Federal parity law compares mental health care with medical and surgical care inside six classifications: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care, and prescription drugs. Within a classification, a financial requirement such as a copay or coinsurance for therapy cannot be more restrictive than the predominant level that applies to most medical and surgical benefits there.
Quantitative limits are numbers: a cap of 20 therapy visits a year, a day limit on a residential stay, or a separate deductible just for mental health. Those must meet the same comparison, and a plan cannot run a separate deductible or out-of-pocket maximum for mental health alone. Nonquantitative treatment limitations (NQTLs) are the rules that are not numbers, including prior authorization, step therapy, medical necessity criteria, network composition and out-of-network reimbursement rates. A plan can use an NQTL on therapy only if the process and evidence behind it are comparable to, and applied no more strictly than, those used for medical care.
- A therapy visit limit with no matching cap on comparable medical visits is a red flag.
- A copay for a therapy visit that is higher than the copay for a primary care or specialist visit may break the financial test.
- Prior authorization required for outpatient therapy but not for comparable outpatient medical care is an NQTL issue.
- A blanket exclusion of a mental health treatment that the plan covers for medical conditions is worth challenging.
Which plans parity covers for adults under 65, and which it does not (2026-2027)
Employer plans with more than 50 employees, individual market coverage, Medicaid managed care, CHIP, and Medicaid benchmark plans are covered by MHPAEA. Small-group plans (generally 1 to 50 employees, and in some states up to 100) are reached through the ACA, which makes mental health and substance use treatment one of the 10 essential health benefits in non-grandfathered individual and small-group plans. A small group of self-funded government plans can opt out of parity, so ask your benefits office.
Original Medicare, including Medicare Part A for inpatient psychiatric stays and Medicare Part B for outpatient therapy, is outside MHPAEA. Under Original Medicare in 2026, Part B pays outpatient mental health visits after the $283 annual deductible, and you pay 20% of the Medicare-approved amount. Medicare Advantage and Medigap rules differ again, so adults under 65 on Medicare because of disability should use the Medicare appeal process instead of the steps below. A preexisting condition such as depression or anxiety can no longer be used to deny or price an ACA-compliant plan.
What the rule looks like in practice, and where enforcement stands (November 2026)
The core parity statute, the 2013 final rule, and the 2021 requirement that plans write and hand over a comparative analysis of their NQTLs on request all remain in force in 2026. A final rule issued in September 2024 added new requirements, but on May 15, 2025 the federal departments announced they would not enforce the parts that are new in that rule. In a March 30, 2026 status report to the court in the pending lawsuit, the departments said they will not defend the 2024 rule and intend to propose replacement regulations by December 31, 2026.
The Department of Labor also issued Field Assistance Bulletin 2026-03 on September 8, 2026, describing the nonquantitative limits it will prioritize when it investigates. For a patient, the practical meaning is that a parity argument in an appeal should rest on the long-standing rules, namely that the limit on your therapy is stricter than the limit on comparable medical care, and on your right to request the plan's comparative analysis. Check the Department of Labor parity page for updates after a new proposed rule appears.
How to appeal a therapy denial or visit-limit denial (2026-2027)
A therapy denial under an ACA-compliant or employer plan follows the same appeal ladder. The denial letter must state the reason and the plan's appeal deadline. In general you have 180 days from the denial notice to file an internal appeal, and the plan decides within about 30 days for care not yet received, and 60 days for care already received. An urgent case is fast-tracked, decided as quickly as your condition requires and often within 72 hours. After a final internal denial, external review is usually requested within 4 months. Read your own notice, because a plan or state can set shorter or longer timelines.
- Step 1: Ask for the denial in writing, with the exact reason, the clinical criteria used, and the claim file.
- Step 2: Ask your therapist or psychiatrist for a letter of medical necessity that describes your diagnosis, symptoms, and why the visit frequency is needed.
- Step 3: File the internal appeal within the deadline and state the parity issue in plain words: the limit on therapy is stricter than the limit on comparable medical care.
- Step 4: Request the plan's NQTL comparative analysis and its medical necessity criteria for both mental health and medical care.
- Step 5: If the internal appeal fails, request an independent external review; the reviewer is not the insurer and the decision binds the plan.
- Step 6: File a parity complaint with the Department of Labor (EBSA) for most employer plans or with your state department of insurance for Marketplace and fully insured plans.
Network adequacy for therapists: a real difference between plans (2027 plan year)
Network composition is one of the NQTLs parity covers, and for therapy it is often the practical problem: a plan can list hundreds of therapists while few are accepting patients. If you cannot get an in-network appointment in a reasonable time, document each call, then ask the plan in writing for an in-network appointment or for out-of-network coverage at the in-network cost. Keep the call log, because it supports both the appeal and a regulator complaint.
Because open enrollment for 2027 Marketplace coverage runs from November 1, 2026 to January 15, 2027, you can compare plans before you commit. Before choosing, search the plan's own provider directory for therapists near you, call two or three to confirm they take that plan, and compare each plan's therapy copay and visit rules. HealthCare.gov lists the dates, and the CoveredUSA open enrollment page explains the deadlines.
Alternatives if your plan still will not cover therapy
Even after an appeal, some adults still need therapy while a dispute continues. Several options exist: the SAMHSA treatment locator at findtreatment.gov lists providers by ZIP code, including sliding-scale clinics; community mental health centers and federally qualified health centers charge by income; the 988 Suicide and Crisis Lifeline offers free support by call or text at any hour; and employee assistance programs often include a set number of free counseling sessions.
- SAMHSA treatment locator (findtreatment.gov): search by ZIP code and insurance.
- Community mental health centers and federally qualified health centers: fees based on income.
- 988 Suicide and Crisis Lifeline: call or text 988 at any hour.
- Employee assistance program through your employer: ask HR about free counseling sessions.
- A large unpaid therapy bill: the CoveredUSA bill analyzer checks it for errors and out-of-network charges.
Frequently Asked Questions
Does my insurance have to cover therapy?
Usually yes. ACA-compliant individual and small-group plans must cover mental health and substance use treatment as an essential health benefit, and large employer plans that cover it must follow parity. Short-term plans and some grandfathered or self-funded government plans can differ, so read your summary of benefits and ask the plan in writing.
Can my plan limit me to a set number of therapy visits?
Only if it applies a comparable limit to medical and surgical care in the same classification. A flat cap such as 20 therapy visits a year, with no equivalent cap on comparable outpatient medical visits, is a parity red flag. Appeal it, cite parity, and ask for the plan's comparative analysis.
What is a nonquantitative treatment limitation?
A nonquantitative treatment limitation (NQTL) is a plan rule that restricts care without using a number, such as prior authorization, step therapy, medical necessity criteria, network design, or out-of-network payment rates. Parity allows an NQTL on therapy only if it is comparable to, and no stricter than, the rules used for medical care.
What is the deadline to appeal a therapy denial?
In general you have 180 days from the denial notice to file an internal appeal with an ACA-compliant or employer plan. After a final internal denial you can request external review, usually within 4 months. Always read the dates on your own denial letter, and ask for an urgent review if delay risks your health.
Is the 2024 parity rule in effect in 2026?
The core parity law, the 2013 rule, and the 2021 comparative analysis requirement are in effect. The federal departments said on May 15, 2025 that they will not enforce the new parts of the 2024 rule, and they plan to propose replacement regulations by December 31, 2026. Parity itself has not been repealed.
Where do I file a parity complaint?
For most job-based plans, contact the Department of Labor's Employee Benefits Security Administration at askebsa.dol.gov or 1-866-444-3272. For Marketplace and fully insured plans, contact your state department of insurance. For Medicaid managed care, contact your state Medicaid agency. Attach your denial letter and appeal records.
Does mental health parity apply to Medicare?
No. Federal parity law does not apply to Original Medicare. Medicare sets its own rules: in 2026 Part B covers outpatient mental health visits after the $283 deductible, with 20% coinsurance of the Medicare-approved amount. Adults under 65 on Medicare because of disability should use Medicare's appeal process, not the parity steps.
