Does Insurance cover Eating Disorders?

An eating disorder will not just impact your physical health; it can severely affect your mental wellness. Often, recovery from an eating disorder requires the help of a professional to tackle the complexity that leads to the development of an eating disorder. Also, recognizing that you have an eating disorder, to begin with, can be difficult to come to terms with.

If you or someone you love is struggling with destructive eating patterns and behaviors, finding a specialist is the best way to overcome the many facets related to eating disorders. If you do require treatment, you may be wondering if eating disorder treatment is covered by medical insurance. 

The answer is “Yes,” insurance companies typically cover treatment; however, the extent and types of coverage can differ from one carrier to the next. Before you either assume that eating disorder treatment isn’t covered or is, these are things that you need to know.

Mental Health Parity Laws

The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law that prohibits group health insurance and health plans from denying access to mental health or substance use disorder treatment. In September of last year, the US Departments of Labor, Health and Human Services, and the Treasury released new updates to implementing MHPAEA. 

The updates include shortened timeframes for request response and nonqualitative treatment limitations. The Act requires that most insurance plans provide equal coverage for mental health conditions, as they do for physical conditions. Since eating disorders are included in mental health conditions, copays, treatment limits, and deductibles for eating disorders should be comparable to your coverage for other medical conditions.

ACA Coverage

The Affordable Care Act, also known as Obamacare, was a reform law enacted in 2010. The goal of the ACA was to expand health insurance coverage for underserved communities and demographics. The Act specifically addressed health insurance to make it more affordable, while also tackling the lack of quality health care for certain Americans. Within the Affordable Care Act is an overhaul of mental health care, which includes treatment for those with eating disorders. It recognizes treatment for eating disorders as “essential health benefits”. ACA- complaint plans require some level of eating disorder treatment coverage.

Levels of Care Covered

Insurance carriers differ in regard to the various levels of care, depending on what is deemed “medically necessary,” which includes:

• Inpatient hospitalization
• Partial hospitalization (PHP)
• Residential treatment
• Outpatient therapy 
• Nutritional counseling
• Intensive outpatient programs (IOP)

What Does the Term “Medically Necessary” Mean?

The term medically necessary refers to health care treatments or services that are required to diagnose, treat, or manage any medical condition. They are in line with deemed acceptable standards of medical practice, or more simply, “A treatment is medically necessary if a doctor can show that it’s essential for your health and not just experimental or optional.” 

What are the Key Factors of “Medically Necessary” Care?

Most insurance carriers define treatment as medically necessary if they have common criteria, such as:

• Appropriate – it is suitable for the patient’s symptoms, condition, and health
• Effective – the treatment has been proven to work and improves one’s health outcome
• Accepted Practice – it follows medical guidelines and isn’t considered experimental
• Not for Convenience – the treatment isn’t just something that makes a patient’s or practitioner’s life easier 
• Least Intensive Option – it isn’t overly expensive or intensive than what is necessary

Medical Necessity and Pre-Authorization

The standard practice for an insurance carrier to cover an eating disorder or condition is that they will require proof by a licensed clinician that the treatment is “medically necessary.” Most often, the patient will need a pre-authorization for treatment that includes clinician assessments, a pre-authorization statement, and medical documentation from a provider. Some insurance companies will also conduct a utilization review that is meant to determine how long an insurance company will cover the proposed treatment.

Provider Networks

Insurance companies typically have providers that are “in-network” or “out-of-network.” Using an in-network provider will usually cost less out-of-pocket. While some insurance plans may not cover out-of-network facilities, others will, but at a lower rate than if the provider chosen is in-network. So, before you choose a clinician for treatment, check with the provider to ensure they accept your insurance carrier. Also, you need to know what portion of the treatment will be covered, and lastly, you need to understand your total out-of-pocket costs.

State Laws

Some states have specific mandates for the treatment of eating disorders that may go beyond the minimum requirements according to federal laws. For example, Illinois and California have laws that ensure broader access to eating disorder care when compared to other states. 

Common Challenges

Even for those who have insurance coverage, there are sometimes hurdles to accessing eating disorder treatment. There are often delays for care due to the pre-authorization process. Also, early discharge, despite clinician approval, can lead to lower recovery rates. And lastly, some insurance carriers will deny claims to delay coverage, which can be repealed, but it takes more time.

What are Some Tips for Navigating Insurance Coverage for Eating Disorders?

Call Your Insurance Company

Don’t assume that you understand how eating disorder coverage works for your specific insurance carrier without calling and talking with them directly. Often, there are exclusions and other factors that you need to know and follow to ensure that you get the coverage you need.

Request a Care Manager

If you want to ensure a seamless process for approval, it is a good idea to request a care manager from your insurance company. They can help you navigate the process and ensure that you do all that you need to get the coverage you need and deserve

Trust, Verify, and Get it in Writing

As with any contract, it is a good idea to get it in writing. Keep a record of all authorization codes and approval dates just in case something goes wrong along the way.

Appeal Denials

Just because you are denied the first time, don’t assume that the case can’t be appealed. Many of the claims submitted upon appeal are overturned when the appropriate documentation is completed. Be persistent and thorough to get the coverage you need.

Ask Your Provider For Assistance

Many providers and treatment centers have insurance advocates on staff or billing teams that are there to help patients with pre-authorizations, claims, and approvals. It is always best to get a professional’s help when it is available.

Final Thoughts on Eating Disorder Insurance Coverage

An eating disorder is something that can damage someone’s health and wellness both physically and mentally. Typically, they require professional help to overcome poor and/or destructive eating patterns and behaviors. 

Before you assume that treatment will be covered, or that it won’t, it is best to know your rights, the laws regarding mental health coverage, and your specific insurance carrier’s rules and obligations. Help is available if you know what you are entitled to and take the proper steps to ensure that you get the treatment you or your loved one needs. Contact us today and let us help!