Mental health and substance use denials: using the parity law

If your plan denied mental health or substance use care, you can make two arguments at once. The first is the ordinary one: the care is medically necessary for you. The second is a parity argument: the plan is holding this care to a stricter standard than it holds comparable medical or surgical care. The first argument is yours and your clinician’s. The second needs documents that only the plan has, so you start by asking for them.

What this means

In plain words: a plan cannot be tougher on mental health care than on comparable medical care, for example by asking for approval more often or reviewing your stay more often.

If you have a Marketplace or other individual plan. The federal parity law at 42 U.S.C. 300gg-26 covers group and individual insurance, so the parity argument is open to you. The document deadline in step 1 and the Employee Benefits Security Administration help line in step 7 are for employer plans covered by the Employee Retirement Income Security Act (ERISA). For an individual plan, ask the plan for the same documents. We could not confirm a deadline for the plan to answer, so ask your state insurance department for help if it does not. We could not confirm how separate rules about essential health benefits extend parity to small-group and individual plans, so ask your regulator how it applies to your plan.

The federal Mental Health Parity and Addiction Equity Act applies to plans and insurers that cover both medical and surgical benefits and mental health or substance use benefits. Financial requirements (such as copays) and treatment limitations on the mental health benefits must be no more restrictive than the predominant ones applied to substantially all medical and surgical benefits. The plan may not have separate limits that apply only to mental health or substance use benefits.

The harder cases involve nonquantitative treatment limitations, the rules that are not simple counts. Examples are prior authorization, medical necessity criteria, “fail first” requirements, how often care is reviewed while you are in treatment, and network rules. The Kennedy Forum, a mental health policy nonprofit that runs the Parity Registry, lists examples: visit caps, stricter prior authorization, excessive concurrent review, and fail-first rules. Its guide says benefits are compared class by class, using six benefit classifications.

Since February 2021, plans and insurers that impose these limits on mental health benefits must perform and document comparative analyses of how the limits are designed and applied, and give them to federal or state regulators on request.

Who is not covered. The parity section of the Employee Retirement Income Security Act (ERISA) does not apply to small-employer group plans. Self-funded non-federal governmental plans with a valid opt-out are exempt, and no new parity opt-outs have been allowed since 29 December 2022. For individual plans, see the box above. For a Medicaid plan, we could not confirm how the parity rules apply, so raise the question in your plan appeal or fair hearing and ask the state Medicaid agency.

Current enforcement status, as checked on 11 November 2026. The 2024 parity final rule (published 23 September 2024) remains in the Code of Federal Regulations. On 15 May 2025 the federal agencies announced they will not enforce the parts of it that are new compared with the 2013 rule until a final court decision in the ERISA Industry Committee lawsuit plus 18 months. The statute, the 2013 rule and the comparative analysis requirement stay in force. On 8 September 2026 the Employee Benefits Security Administration issued a bulletin that narrows its enforcement focus to three areas: exclusions that apply only to mental health benefits, medical necessity standards and review (prior authorization, concurrent and retrospective review), and network adequacy. The bulletin says it creates no enforceable rights. In a court filing of 30 September 2026, the agencies said they will issue a new proposed rule and intend to send it for White House review by 18 December 2026. We read that filing from a university-hosted copy, not an official court site. No proposed rule had been published as of 11 November 2026.

What to do

1. Request the documents. Use the parity comparison request letter. Ask for the medical necessity criteria for the denied care and for comparable medical and surgical care, the processes and evidentiary standards the plan used, and its comparative analysis. For ERISA plans, these documents must be furnished within 30 days of a request. If your employer is a government or a church, ask the plan whether ERISA applies. Medical necessity criteria for mental health and substance use benefits must be given to any participant on request. The reason for a denial of this care must also be given on request. (You.)
2. Get your own facts in order. Ask for your claim file. Write what the denied care is, who ordered it, and what your clinician says will happen without it. (You.)
3. Ask your clinician for a medical necessity letter. It should apply the plan’s own criteria to your history. See the guide on level-of-care denials for residential or inpatient care. (Your clinician.)
4. File the appeal, with both arguments. Use the mental health parity appeal letter. Put the clinical case first. Then identify the limit you think is stricter (for example, a fail-first rule, a review schedule or an exclusion), say you have requested the comparison, and ask the plan to explain how it applies the same limit to medical care. Raise parity in the internal appeal. The Kennedy Forum’s guide says doing so preserves the issue for later steps. That is a nonprofit’s advice, not a legal rule, and it puts the point on the record. Employer plans and non-grandfathered individual plans must allow at least 180 days after you receive the denial. Check the date on your notice, which controls. (You.)
5. Ask for an urgent decision if delay could harm you. Your clinician certifies urgency. An urgent appeal is due within 72 hours. (Your clinician.)
6. Request external review. Under the federal process, whether the plan complied with parity rules on these limits is a medical-judgment matter eligible for the federal external review process. You have at least four months after the final internal denial. If your plan is regulated by a state that runs its own process, see your state page. We could not confirm whether a state process decides parity complaints, so ask the regulator. (You.)
7. Complain to the regulator. For a private employer plan, the Employee Benefits Security Administration’s help line is 1-866-444-3272. For an insured plan, complain to the state insurance department. Self-funded non-federal governmental plans are regulated by the Centers for Medicare & Medicaid Services. (You.)

What the plan may say, and what to say back

“This level of care is not medically necessary under our criteria.” Ask for the criteria, who wrote them and the clinical reasoning applied to your case. Ask for the criteria used for comparable medical care.

“Our review process applies equally to all benefits.” Ask for the comparative analysis, in writing. The law requires the plan to have performed and documented it.

The rule

A plan must ensure financial requirements and treatment limitations on mental health and substance use disorder benefits are no more restrictive than the predominant ones applied to substantially all medical and surgical benefits, and must document comparative analyses of nonquantitative limits. 29 United States Code (U.S.C.) 1185a

Watch for

• In California. California law requires plans and insurers to cover medically necessary treatment of mental health and substance use disorders on the same terms as other medical conditions, bars limiting it to short-term or acute care, and requires medical necessity to be decided using current generally accepted standards of care. See Senate Bill 855 (2020), Chapter 151; Health and Safety Code sections 1374.72 and 1374.721 and Insurance Code sections 10144.5 and 10144.52, at the California Legislative Information page. State laws generally do not reach self-funded employer plans. The California page lists the state regulators.
• The Parity Registry collects stories. Its complaint form is for advocacy. It is not the same as an appeal or a regulator complaint, and it does not resolve your case.
• State laws. Many states add their own parity rules for insured plans. See California, Colorado, Massachusetts and Texas for examples. State rules generally do not reach self-funded employer plans.
• A court ruling or new rule can change this page. Check the date at the top.

What next

• Level-of-care denials: if the plan refused residential, inpatient or intensive care.
• Not medically necessary: the clinical argument in detail.
• How external review works: the independent review process.
• Mental health and substance use topic page: all related guides and letters.