On July 6, the House approved legislation intended to improve access to mental health treatment and strengthen enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). The bill would clarify that benefits for eating disorders (including residential treatment) must comply with the MHPAEA.

A separate House bill would expand health savings accounts (HSAs), health flexible spending accounts (FSAs) and health reimbursement arrangements (HRAs). That legislation would:

  • Repeal the provision in the Affordable Care Act (ACA) that prohibits HSAs, health FSAs and HRAs from paying or reimbursing drugs or medications unless they are prescribed
  • Increase the HSA contribution limits
  • Allow both spouses to make catch-up contributions to the same HSA
  • Allow reimbursement of medical expenses incurred before the HSA is established

Helping Families in Mental Health Crisis Act

The Helping Families in Mental Health Crisis Act (H.R. 2646) passed the House by an overwhelming majority — the vote was 422 to 2. The bill aims to expand access to mental health treatment, strengthen oversight of mental health programs, and improve public health and safety. It responds to concerns about noncompliance with the MHPAEA, including compliance by plans that use nonquantitative treatment limits.1

The act calls for additional guidance to help group health plans and health insurance issuers comply with the MHPAEA. The secretaries of Health and Human Services (HHS), Labor (DOL) and Treasury would be required to issue a compliance guidance document containing illustrative, de-identified examples of compliance and noncompliance, based on prior investigations. The document must also provide examples showing the proper application of nonquantitative treatment limits and include recommendations, as well as other guidance.

Health plans and health insurance issuers would have to disclose criteria for medical necessity determinations, justification for benefit denials and other information to demonstrate compliance with the MHPAEA to current and potential participants, beneficiaries and contracting providers upon request.

HHS would work with other stakeholders — including the DOL, Treasury, Department of Justice, state governments, employers and others — to develop an action plan for improved federal and state coordination of the MHPAEA that would:

  • Facilitate centralized collection of and responses to patient complaints or inquiries relating to parity requirements
  • Require that federal and state law enforcement agencies enter into memoranda of understanding to better coordinate enforcement
  • Make recommendations to Congress about the need to strengthen enforcement of parity requirements, “including the need for additional legal authority” to ensure plan compliance with nonquantitative treatment limitations

The Government Accountability Office (GAO) would report on how well group health plans are complying with parity requirements and develop recommendations for additional enforcement.

Restoring Access to Medication and Improving Health Savings Act

The Restoring Access to Medication and Improving Health Savings Act (H.R. 1270) passed the House by a 243 – 164 vote. It would allow HSAs, health FSAs and HRAs to reimburse over-the-counter drugs and medications without a prescription. The bill also includes provisions from HSA legislation (H.R. 5445) approved by the House Ways and Means Committee in June that incorporated HSA expansions and improvements recommended by Speaker Ryan’s health care reform task force:

  • Make the maximum annual HSA contribution limits equal to the annual out-of-pocket limit for high-deductible health plans (HDHPs)
  • Allow both spouses to make catch-up contributions to the same HSA
  • Allow HSAs to reimburse medical expenses incurred before the account was established, as long as the eligible individual establishes the HSA within 60 days of joining an HDHP

To offset the cost of these changes, the legislation would increase the recovery of subsidies overpaid through the public insurance exchanges as follows:

  • Under current law, the maximum required subsidy repayment is $600 for households with incomes up to 200% of the federal poverty level (FPL), $1,500 for incomes that are 200% to 300% of the FPL, and $2,550 for incomes that are 300% to 400% of the FPL.
  • Under the proposed legislation, the maximum required subsidy repayment would be $1,500 for households with incomes of 200% to 250% of the FPL, and $3,000 for incomes between 250% and 300% of the FPL. There would be no limit for incomes that exceeded 300% of the FPL.


Both bills now move to the Senate, where the timing and outlook for additional action is unclear. The White House has said that President Obama will veto the Restoring Access to Medication and Improving Health Savings Act if it reaches his desk.

The mental health parity legislation occurred in tandem with a greater regulatory and enforcement focus on the MHPAEA. The HSA and FSA provisions advance some proposals issued by the House health care reform task force, and reinforce political messaging ahead of the November elections.


1. Examples of nonquantitative treatment limitations include medical management, step therapy and pre-authorization.