The Federal Government Just Identified the Insurance Practices That Can Block Addiction Treatment

On September 8, 2026, the U.S. Department of Labor’s Employee Benefits Security Administration issued new enforcement guidance focused on barriers to mental health and substance use disorder benefits.

Field Assistance Bulletin 2026-03 outlines how the agency plans to approach enforcement of the Mental Health Parity and Addiction Equity Act, or MHPAEA, particularly its requirements governing nonquantitative treatment limitations.

The Department of Labor identified three areas as current enforcement priorities:

1. 01Separate treatment limitations, including exclusions
2. 02Medical-necessity standards and review processes
3. 03Standards for determining network adequacy, including provider admission standards and reimbursement methodologies

The agency also released updated guidance identifying examples of plan provisions and operational practices that may indicate potential MHPAEA compliance problems.

For substance use disorder treatment, those examples include exclusions involving medications for addiction treatment, residential treatment, intensive outpatient programs and partial hospitalization programs, as well as differences in prior authorization practices and provider-network standards.

01What the Mental Health Parity and Addiction Equity Act Covers

The Mental Health Parity and Addiction Equity Act generally prohibits group health plans and health insurance issuers subject to the law from applying more restrictive financial requirements or treatment limitations to mental health and substance use disorder benefits than to comparable medical and surgical benefits.

The law does not prohibit health plans from using tools such as prior authorization, medical-necessity criteria or provider-network standards. Instead, MHPAEA regulates how those limitations are designed and applied when mental health or substance use disorder benefits are compared with medical and surgical benefits.

Some of the restrictions covered by the law are known as nonquantitative treatment limitations, or NQTLs.

These can include:

• Prior authorization
• Concurrent review
• Medical-necessity criteria
• Provider admission standards
• Provider reimbursement methodologies
• Step-therapy requirements
• Treatment exclusions
• Network-management practices

The Department of Labor states that addressing barriers to mental health and substance use disorder benefits is a national enforcement priority.

02Addiction Medication Exclusions Are Among the Practices Identified by the Department of Labor

The Department of Labor’s updated guidance specifically identifies exclusions involving medications used in addiction treatment as one potential area of concern.

The guidance lists:

• Methadone
• Naltrexone
• Buprenorphine

It states that exclusions involving these medications, or other evidence-based treatments for opioid or other substance use disorders, may indicate a potential parity issue, particularly when comparable services or the same medications are covered for medical or surgical conditions.

This distinction is important because MHPAEA generally involves comparisons between how a plan applies restrictions to mental health or substance use disorder benefits and how it applies comparable restrictions to medical and surgical benefits.

03Residential Treatment, IOP and PHP Are Also Included in the Guidance

The Department of Labor separately identifies exclusions of certain intermediate levels of mental health and substance use disorder care.

The guidance specifically references:

• Residential treatment programs
• Intensive outpatient programs
• Partial hospitalization programs

According to EBSA, excluding those services may raise parity concerns when comparable intermediate levels of medical or surgical care, such as skilled nursing, home health or rehabilitation services, are covered by the same plan.

This places several forms of addiction treatment directly within the Department of Labor’s current enforcement framework.

Residential treatment generally provides 24-hour structured care outside a hospital setting. Intensive outpatient and partial hospitalization programs provide higher-intensity treatment than standard outpatient services without requiring continuous residential placement.

Whether those services are covered, and what restrictions apply to them, can vary by health plan.

04Prior Authorization Is Another Area Under Review

Medical-necessity standards and review processes make up the second major category identified in Field Assistance Bulletin 2026-03. The Department of Labor’s updated guidance lists several examples of practices that may indicate unequal treatment between behavioral-health and medical benefits.

One example involves plans that require prior authorization or concurrent review for all or nearly all mental health and substance use disorder benefits while requiring those reviews for few or no comparable medical or surgical benefits within the same classification.

The guidance identifies potentially relevant disparities such as:

• Longer authorization timelines for mental health or substance use disorder claims
• Manual and more burdensome review processes for behavioral-health claims when medical claims use automated systems
• Shorter authorization periods for mental health or substance use disorder services
• Different levels of scrutiny applied to continued-stay requests

EBSA also identifies certain requirements that can appear in medical-necessity policies, including step-therapy or fail-first requirements, treatment-plan submission requirements and criteria related to patient participation or motivation.

The presence of one of these practices does not by itself establish a violation. The parity analysis depends on how the process compares with the standards and practices applied to medical and surgical benefits.

05Network Adequacy Is a Major Part of the New Enforcement Focus

The third major enforcement area involves standards used to determine network adequacy. The Department of Labor’s guidance identifies several examples of potential differences between mental health and substance use disorder networks and medical or surgical networks.

These include more burdensome processes for behavioral-health providers seeking to participate in a network, longer delays before approved providers appear in directories and different reimbursement methodologies.

The agency also identifies differences in network-gap procedures.

For example, the guidance describes situations in which a health plan provides procedures for members who cannot locate an available in-network medical provider but does not provide comparable procedures for mental health or substance use disorder services.

These procedures may include:

• Network-gap exceptions
• Single-case agreements
• Out-of-network exceptions
• Arrangements that apply in-network benefits to an out-of-network provider

The Department of Labor states that applying more burdensome standards to obtain these accommodations for mental health or substance use disorder treatment may indicate a potential parity issue.

06Provider Reimbursement Can Affect Network Adequacy

Provider reimbursement methodologies are also specifically included in the Department of Labor’s network-adequacy guidance. EBSA identifies differences in reimbursement calculations between mental health or substance use disorder providers and medical or surgical providers as a potential compliance concern.

The guidance gives the example of a plan applying a percentage reduction to reimbursement rates for certain behavioral-health providers while not applying the same reduction, or applying a smaller reduction, to comparable medical providers.

According to the guidance, potential concerns may arise when a plan makes targeted efforts to recruit medical providers in areas with network gaps but does not make similar efforts when comparable or greater gaps exist in its mental health or substance use disorder network.

These examples connect provider reimbursement and network-development practices with the broader question of whether covered services are practically available through a plan’s network.

07Out-of-Network Use Can Reveal Differences in Access

The Department of Labor also identifies out-of-network utilization as one measure that can provide information about how a behavioral-health network is functioning.

The guidance states that substantially higher out-of-network use for mental health or substance use disorder services compared with medical and surgical services may suggest differences in the processes used to build or maintain those networks.

EBSA also identifies a disproportionate number of complaints about difficulty accessing in-network mental health or substance use disorder providers as another potential indicator. These measures do not independently establish noncompliance.

They can, however, provide information about whether there are material differences between behavioral-health and medical networks that may warrant further examination under MHPAEA.

08The Guidance Also Addresses How Plans Operate in Practice

The Department of Labor’s September guidance extends beyond written plan language. EBSA identifies several operational differences that may not be apparent from a policy document alone.

Examples include:

• Mental health or substance use disorder authorizations taking longer in practice
• Behavioral-health claims requiring more manual documentation
• Behavioral-health providers facing more burdensome network-admission processes
• Different efforts to correct provider shortages
• Different standards for network-gap exceptions
• Higher out-of-network utilization for behavioral-health services

The agency’s guidance therefore places attention on both written plan provisions and how benefits are administered in actual practice.

09The 2026 Guidance Comes During an Ongoing Federal Review of MHPAEA Rules

The current enforcement framework follows several years of regulatory changes. In September 2024, the Departments of Labor, Health and Human Services, and Treasury issued a final rule updating MHPAEA requirements.

The rule amended the 2013 regulations and added provisions related to the comparative analysis of nonquantitative treatment limitations. In January 2025, the ERISA Industry Committee filed a lawsuit challenging portions of the rule.

That nonenforcement policy applies until a final decision in the litigation, plus an additional 18 months. The departments also stated that MHPAEA’s underlying statutory obligations, including requirements added by Congress through the Consolidated Appropriations Act of 2021, remain in effect.

Field Assistance Bulletin 2026-03 provides additional detail about how the Department of Labor intends to approach enforcement during this period. The bulletin states that EBSA is seeking a more streamlined enforcement framework while continuing to address barriers to mental health and substance use disorder benefits.

10What the New Enforcement Priorities Show About Addiction Treatment Coverage

The September 2026 guidance identifies several parts of health-plan administration that can influence access to substance use disorder treatment.

These include:

• Whether certain addiction medications are excluded
• Whether residential, intensive outpatient or partial hospitalization treatment is excluded
• How medical-necessity standards are applied
• How frequently prior authorization is required
• How long authorization decisions take
• How behavioral-health providers enter insurance networks
• How providers are reimbursed
• Whether comparable network-gap exceptions are available
• How often members rely on out-of-network care

Together, these categories show that insurance coverage can involve more than the presence or absence of a substance use disorder benefit.

The structure of the network, the level of care available within that network, utilization-review processes and the treatment services included in the benefit can all affect how that coverage operates in practice.

11Coverage and Access Are Separate Measures

Health-plan documents can establish whether a particular category of substance use disorder treatment is covered.

They do not, by themselves, establish whether an appropriate provider is geographically available, accepting patients, participating in the relevant network or providing the required level of care.

The Department of Labor’s emphasis on network adequacy reflects that distinction. Its new guidance specifically addresses differences in provider availability, network-gap procedures, provider recruitment, reimbursement methodologies and out-of-network use.

Those factors can produce different real-world access conditions even among plans that formally include substance use disorder benefits. The September 2026 guidance does not establish that every restriction, denial, network limitation or treatment exclusion violates federal parity law.

Instead, it identifies categories of practices that EBSA says have appeared as potential compliance concerns in investigations and establishes the areas that the agency currently intends to prioritize in its enforcement of MHPAEA.

As the federal government continues to reconsider portions of the 2024 parity regulations, treatment exclusions, medical-necessity review and behavioral-health network adequacy are now at the center of the Department of Labor’s stated enforcement approach.