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

The federal government weakened mental health insurance protections for 153 million Americans. Only 13 states pushed back.

By Myryah Irby

Updated: April 20, 2026

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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 plans, primarily large-employer plans rather than 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 documenting where protections hold and where gaps leave enrollees 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.

KEY FINDINGS

Federal agencies paused new parity requirements. On May 15, 2025, DOL, HHS and Treasury announced they would not enforce provisions of the 2024 MHPAEA Final Rule that are new relative to the 2013 rule, for the duration of litigation plus 18 months after a final court decision. The underlying MHPAEA statute and 2013 rule remain in effect.
Staffing and budget cuts have weakened the agency that reviews parity violations. The Employee Benefits Security Administration (EBSA), which oversees parity compliance for employer-sponsored plans covering an estimated 153 million workers and dependents, has a proposed $10 million budget cut pending. Trade groups report about 200 staff departures in 2025.
Only 13 states have strong parity protections. California, Georgia, New York, Illinois, Washington, Colorado, Connecticut, Maryland, Massachusetts, Pennsylvania, Delaware, New Mexico and Tennessee have enacted laws or taken enforcement actions that go beyond federal requirements.
Georgia issued nearly $25 million in fines. Commissioner John King logged more than 6,000 parity violations across 22 insurers in 2025 and 2026, the largest state enforcement action in MHPAEA history. The enforcement push came from Republican-led Georgia, while Democratic-led New Jersey earned a ParityTrack "F" despite a larger insurance market.
Federal agencies are drafting a replacement rule. On March 30, 2026, the departments of Labor, Health and Human Services, and Treasury told the U.S. District Court for the District of Columbia they won't defend the 2024 rule in the ERIC lawsuit. They plan to issue a new proposed rule with major revisions by Dec. 31, 2026.
Racial disparities in mental health access could widen under weaker enforcement. Among adults with mental health issues, 39% of Black adults, 36% of Hispanic adults and 33% of Asian adults received care, compared to 50% of white adults.
State legislatures are moving despite federal inaction. In 2025, 29 states enacted 75 bills addressing mental health coverage, parity requirements and workforce issues.

What Changed and Why

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.

The nonenforcement policy applies only to the 2024 rule's new provisions. MHPAEA's core statutory requirements remain in effect. The agencies, however, aren't enforcing the documentation, comparative analysis and results-data requirements.

Coverage Effects Without Federal Enforcement

Three plan-level changes become possible when insurers aren't required to prove their mental health restrictions are justified:

1
Higher cost-sharing
Insurers can set higher copayments or deductibles for therapy than for a comparable medical visit, with no requirement to justify the difference. DOL enforcement actions in FY 2023 required plans to reimburse members for excess cost-sharing on mental health benefits and for coinsurance on mental health drugs that wasn't applied to other prescription drugs.
2
Narrower provider networks
Insurers can narrow mental health networks without documenting that the restriction matches their approach to medical care.
3
Expanded prior authorization requirements
Insurers can require prior authorization for therapy sessions without imposing it on comparable medical visits. Prior authorization for mental health services was the most common violation DOL found in its FY 2023 enforcement reviews.

Without DOL enforcement of the new requirements, disputes over whether these restrictions violate MHPAEA fall to enrollees and plan sponsors to pursue. A February 2025 audit by the DOL's Office of Inspector General found EBSA lacked civil monetary penalty authority and had limited ability to bring actions against all responsible parties before the pause.

MoneyGeek's 50-State Parity Protection Index

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


California	Strong	SB 855/AB 988 parity act; final rulemaking 2025	Active enforcement	Kaiser settlement; CDI enforcement powers expanded
Georgia	Strong	HB 1013 enforcement; SB 131 parity compliance panel	Active enforcement	$25 million in fines; 6,000+ violations across 22 insurers
New York	Strong	$2.5 million+ in fines for non-compliance; UnitedHealthcare action	Active enforcement	$18 million+ UnitedHealthcare settlement
Illinois	Strong	Only state to earn ParityTrack "A" grade (100/100)	Active enforcement	$500,000 fines (2023); mandatory parity audits
Washington	Strong	HB 1432 codifies 2024 federal rule into state law	Effective July 27, 2025	Covers all health carriers
Colorado	Strong	HB 25-1002 codifies federal MHPAEA; requires clinical criteria	Effective Jan. 1, 2026	Bipartisan support
Connecticut	Strong	Fines up to $625,000/year for parity violations (2025 law)	Active enforcement	New penalty authority
Maryland	Strong	Stricter insurer parity analysis requirements adopted	Active enforcement	Reimbursement rate scrutiny
Massachusetts	Strong	Full parity for biologically-based mental illnesses since 2001	Active enforcement	Settlements with 5 insurers covering 1 million+ residents
Pennsylvania	Strong	Baseline MHPAEA compliance exams for each insurer	Active enforcement	Capital Blue Cross: $85,000 fine + restitution
New Mexico	Strong	SB 120: no cost-sharing for behavioral health services	Active	Copays, coinsurance, deductibles eliminated for MH
Delaware	Strong	Annual parity reporting requirements; prior authorization reform for SUD	Active	Reporting requirements for insurers
Tennessee	Strong	ParityTrack 79/100 (2nd highest); mental health parity reporting	Active	Reporting requirements enacted
Oregon	Moderate	Fourth annual parity report; outcome-based oversight	Active monitoring	Claims denial disparity tracking
Virginia	Moderate	HB 1760 (infant MH act); HB 2738 (standards of care)	New legislation 2025	Coverage with accepted standards
West Virginia	Moderate	Data-driven oversight: denied claims and prior auth data	Active monitoring	Insurer data requests
New Hampshire	Moderate	MH provider reimbursement rate scrutiny	Active monitoring	Commonwealth Fund study state
Rhode Island	Moderate	Enforcement tools under review	Active monitoring	Commonwealth Fund study state
Alaska	Moderate	SB 45: Medicaid parity utilization review	New legislation 2025	Medicaid-focused
Oklahoma	Moderate	HB 2049: Medicaid parity reporting requirements	Pending	Medicaid-focused
Ohio	Moderate	Limited parity legislation	Partial	Some state requirements
Florida	Moderate	CMS collaborative enforcement agreement	Federal-state	Limited state action
Texas	Moderate	CMS direct enforcement; psychiatry loan repayment ($180,000)	Federal enforcement	Workforce incentives
Minnesota	Moderate	State parity requirements on books	Partial enforcement	Some state protections
Wyoming	Weak (10/100)	HHS exercises enforcement authority	No state enforcement	CMS direct enforcement only
Nevada	Weak (54/100)	Regulators cited parity violations across carriers	Minimal	Cost-sharing disparities flagged
Mississippi	Weak (57/100)	Minimal enforcement history	Minimal	Federal reliance
Maine	Weak (76/100)	No active enforcement mechanism	Minimal	High statutory score; no action
New Jersey	Weak	ParityTrack "F" grade for insurance parity coverage	Minimal	Low statutory protections
Arizona	Weak	No forward movement since federal nonenforcement announcement	Stalled	No active enforcement
Missouri	Weak	CMS direct enforcement (FY 2022); limited state action	Minimal	Federal reliance
Kansas	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Montana	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Idaho	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
South Dakota	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Utah	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Arkansas	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
North Carolina	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
South Carolina	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Indiana	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Iowa	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Kentucky	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Louisiana	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Michigan	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Wisconsin	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Nebraska	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Alabama	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Hawaii	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
North Dakota	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement
Vermont	Weak	No active enforcement beyond federal baseline	Minimal	No active enforcement

Source: ParityTrack, MultiState, Commonwealth Fund, Kennedy Forum, DOL enforcement reports and state insurance commissioner offices. Classification reflects MoneyGeek's analysis of state legislation, enforcement actions and regulatory activity from 2024 through early 2026.

Where Coverage Gaps Are Largest

Enrollees in the 26 Weak-tier states are most exposed. These states relied primarily 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 primary enforcer for Wyoming in fiscal year 2022, but the federal role has diminished. Missouri and Texas also relied on CMS federal enforcement rather than state-level action.

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

DOL enforcement data documents the scope 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.

THE GEORGIA FACTOR

Georgia Commissioner John King logged more than 6,000 parity violations across 22 insurers in 2025 and 2026 — the largest state enforcement action in MHPAEA history. New Jersey, with a Democratic governor and a larger insurance market, earned an "F" from ParityTrack despite Georgia's Republican leadership.

Over the past six years, 10 states implemented corrective actions against more than 30 health plans, totaling more than $31 million in fines. Georgia accounts for $25 million of that total; the other nine states combined account for $6 million. At Georgia's enforcement rate, the national total would be much higher.

Enrollees in states without strong MHPAEA enforcement bear the cost through their employer-sponsored plans. Large employers, represented by groups like ERIC, pushed back against the federal rule. Without DOL reviews of the new requirements, employers operate with less pressure to negotiate stronger mental health benefits.

Who Is Most Affected

Racial and ethnic disparities in mental health care access are well documented. The KFF Survey of Racism, Discrimination and Health found that among adults with mental health issues, 39% of Black adults, 36% of Hispanic adults and 33% of Asian adults received mental health care, compared to 50% of white adults. Researchers and advocates warn that parity enforcement gaps can widen these disparities.

Young adults aged 18 to 25 have the highest rates of mental illness, per SAMHSA's National Survey on Drug Use and Health. This group also has 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 by state.

State-Level and Plan-Level Options

Federal enforcement remains limited while litigation continues. State-level action and individual complaints remain meaningful channels.

1
State tier classifications
The parity protection index above classifies each state as Strong, Moderate or Weak based on statutory protections and enforcement activity.
2
Plan-level parity comparisons
Parity violations often surface in plan documents when mental health benefits carry different copayments, deductibles, therapy visit limits, pre-authorization requirements or network restrictions than comparable medical benefits. Summary of Benefits and Coverage documents are the baseline used for comparison.
3
State enforcement pathways
State insurance commissioners retain enforcement authority despite the federal pause. California, Georgia and Washington are reviewing parity violations through state-level channels.
4
Recent state legislative action
Washington's HB 1432 codified the 2024 federal rule into state law. Colorado's HB 25-1002 requires nationally recognized clinical criteria for behavioral health coverage decisions. Both passed with bipartisan support in 2025.
5
Employer-sponsored plan oversight
Group health plans fall under MHPAEA requirements, and benefits managers can provide compliance data showing how the plan applies mental health and medical benefits.

Methodology

MoneyGeek built 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 and DOL MHPAEA enforcement fact sheets for FY 2022 through FY 2024. The index also incorporates a review of state legislation and insurance commissioner actions. The research ran from February to 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 come from KFF's 2023 Survey of Racism, Discrimination and Health. The Federal Register, DOL press releases, the DOL OIG February 2025 audit report and court filings document the 2024 Final Rule and enforcement pause.

About Myryah Irby

Myryah Irby is a writer and data journalist at MoneyGeek. Her work spans original data studies and how-to guides covering auto, home and health insurance, consumer costs, and transportation safety.

Research and Analysis

Since joining MoneyGeek in late 2025, Irby has produced data studies on insurance costs, consumer spending and transportation risk. Her published work includes a 50-state analysis of winter driving danger using fatality and weather severity data; research tracking the relationship between rhodium commodity prices and catalytic converter theft rates, including state-level theft trends and what those rates mean for insurance costs; a state-by-state comparison of winter home heating costs; and an analysis of the full cost of having a baby in America: hospital bills, insurance and out-of-pocket expenses.

Career

Irby has more than 20 years of editorial and writing experience. Since 2005, she has run Irby x Irby, her own editorial and copywriting practice, with clients including The New York Times, The San Francisco Chronicle, OpenAI and the National Park Service. From 2019 to 2023, she served as Senior Managing Editor and then Copywriting Manager at Callisto Media, a nonfiction publisher acquired by Penguin Random House in May 2023, where she led a team of writers and graphic designers.

Before that, she spent nearly 11 years at QuinStreet, a performance marketing company that runs content and comparison sites in insurance and personal finance. She rose from Managing Editor to Senior Managing Editor between 2010 and 2016. Earlier in her career, she edited at Collabrys for nearly four years and tutored doctoral candidates on dissertation writing at the University of San Francisco.

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Sources

American Psychiatric Association. "Departments Announce Nonenforcement of 2024 Mental Health Parity Rule." Accessed May 22, 2026.
Becker’s Behavioral Health. "Trump Administration to Propose New Parity Rule." Accessed May 22, 2026.
Bloomberg Law. "Agencies Plan Mental Health Parity Proposal by End of Year." Accessed May 22, 2026.
California Department of Insurance. "Commissioner Lara Expands Mental Health Access With Final Landmark Rulemaking." Accessed May 22, 2026.
Centers for Medicare & Medicaid Services. "The Mental Health Parity and Addiction Equity Act (MHPAEA)." Accessed May 22, 2026.
Commonwealth Fund. "Enforcing Mental Health Parity: State Options to Improve Access." Accessed May 22, 2026.
Commonwealth Fund.. "Behavioral Health Parity Takes Step Backward Under Trump Administration." Accessed May 22, 2026.
KFF. "Racial and Ethnic Disparities in Mental Health Care: Findings from the KFF Survey of Racism, Discrimination and Health (2023)." Accessed May 22, 2026.
KFF. "Employer Health Benefits Survey: Annual Survey Results." Accessed May 22, 2026.
Kennedy Forum / ParityTrack. "State Parity Implementation: Ranking Criteria and State Reports." Accessed May 22, 2026.
MultiState. "State Behavioral Health Legislative Trends in 2025." Accessed May 22, 2026.
U.S. Department of Health and Human Services. "Federal Register: Requirements Related to the Mental Health Parity and Addiction Equity Act (Sept. 23, 2024)." Accessed May 22, 2026.
U.S. Department of Labor. "FY 2022 MHPAEA Enforcement Fact Sheet." Accessed May 22, 2026.
U.S. Department of Labor. "FY 2023 MHPAEA Enforcement Fact Sheet." Accessed May 22, 2026.
U.S. Department of Labor. "Statement Regarding Enforcement of the Final Rule on Requirements Related to MHPAEA (May 15, 2025)." Accessed May 22, 2026.
U.S. Department of Labor, Office of Inspector General. "EBSA Faced Challenges Enforcing Compliance with Mental Health Parity (Report 09-25-001-12-001, February 2025)." Accessed May 22, 2026.