Only 13 States Offer Strong Mental Health Coverage Protections After Federal Rollback

Federal officials paused enforcement of major parts of the 2024 mental health parity rule, leaving an estimated 153 million workers and dependents covered by employer-sponsored health insurance plans (mostly large employer plans, not Medicare or Medicaid) with weaker protections. Most states haven't stepped in to fill the gap.

MoneyGeek analyzed legislation, enforcement actions and regulatory data for all 50 states to build a parity protection index showing where consumers are protected and where gaps leave them exposed. Only 13 states have laws or enforcement activity that go beyond the federal baseline. ParityTrack gave 32 states an "F" grade on its statutory evaluation.

The Mental Health Parity and Addiction Equity Act of 2008 requires health insurance plans to cover mental health services on equal terms with physical health care. In September 2024, the Biden administration published the most detailed expansion of MHPAEA since the 2013 final rule. The 2024 rule required insurers to document that any limits they place on mental health care, including fewer therapy visits, stricter network requirements or higher cost-sharing, are justified by independent medical evidence.

In January 2025, the ERISA Industry Committee (ERIC), a trade group representing large employers, sued to block the rule. On May 15, 2025, DOL, HHS and Treasury issued a joint statement saying they would not enforce the 2024 rule's new provisions during the litigation or for 18 months after a final resolution.

On March 30, 2026, the agencies went further. In a joint status report to the U.S. District Court for the District of Columbia, they told the court they won't defend the 2024 rule at all and plan to issue a new proposed rule with significant revisions by December 31, 2026. This shifts the story from a temporary enforcement pause to an active rewrite of the rule itself.

The nonenforcement policy applies only to the 2024 rule's new provisions. MHPAEA's core statutory requirements remain in effect. But the documentation, comparative analysis and results-data requirements are not currently being enforced.

Three changes can happen when insurers aren't required to prove their mental health restrictions are justified:

Without DOL enforcement of the new requirements, disputes over whether these restrictions violate MHPAEA fall to individual consumers or their employers to address. A February 2025 audit by the DOL's Office of Inspector General found EBSA already lacked civil monetary penalty authority and had limited ability to bring actions against all responsible parties even before the pause.

MoneyGeek developed a 50-state parity protection index using ParityTrack's statutory evaluation scores, the Kennedy Forum's enforcement action tracker, Commonwealth Fund enforcement studies, MultiState's 2025 legislative analysis and direct review of state enforcement data from 2024 through early 2026.

Consumers in the 26 Weak-tier states are most exposed. These states relied almost entirely on DOL enforcement of the 2024 rule's new requirements to hold insurers accountable.

Wyoming has the lowest ParityTrack score in the country at 10 out of 100. HHS stepped in as direct enforcer for Wyoming in fiscal year 2022, but that federal role is now diminished. Missouri and Texas also relied on CMS direct enforcement rather than state-level action.

Maine scores 76 out of 100 on ParityTrack's statutory evaluation but has no active enforcement mechanism. High statutory scores without enforcement give patients limited recourse when insurers don't comply.

The DOL's own enforcement data shows the scale of the problem. In fiscal year 2023, EBSA reviewed 51 plans for MHPAEA compliance and found 31 violations across 17 investigations. One corrective action removed visit caps on autism therapy across plans covering millions of participants.

Racial and ethnic disparities in mental health care access are already serious. The KFF Survey of Racism, Discrimination and Health found that among adults with mental health issues, only 39% of Black adults, 36% of Hispanic adults and 33% of Asian adults received mental health care, compared to 50% of White adults. Parity enforcement gaps make those disparities worse.

Young adults aged 18 to 25 have the highest rates of mental illness per SAMHSA's National Survey on Drug Use and Health. They also have lower rates of health insurance coverage and access to care. MoneyGeek's analysis of youth mental health access by state shows the gap in access and cost varies widely depending on where young people live.

MoneyGeek developed its 50-state parity protection index using ParityTrack's statutory evaluation scores, the Kennedy Forum's enforcement action tracker, Commonwealth Fund enforcement studies, MultiState's 2025 behavioral health legislative analysis, DOL MHPAEA enforcement fact sheets for FY 2022 through FY 2024 and direct review of state legislation and insurance commissioner actions. Research was conducted between February and April 2026.

Strong states have enacted laws exceeding federal MHPAEA requirements or have documented enforcement actions. Moderate states have active monitoring programs, new parity-related legislation or federal-state collaborative enforcement. Weak states have no documented enforcement activity beyond the federal baseline.

Mental health care access disparities are cited from KFF's 2023 Survey of Racism, Discrimination and Health. The 2024 Final Rule and enforcement pause are documented in the Federal Register, DOL press releases, the DOL OIG February 2025 audit report and court filings.