Breaking Down Barriers to Coverage for Eating Disorders Treatment

Despite widespread awareness of eating disorders, only about a third of those with anorexia nervosa (AN) and only 6% with bulimia nervosa (BN) receive mental health care (NEDA Statistics). For those who do manage to get treatment, the cost ranges from $500 to $2,000 per hospital day in the US. A month of inpatient treatment can easily reach $30,000. The cost of treatment, including therapy and medical monitoring, can extend to $100,000 or more (NEDA).

Insurance companies use a number of tactics to avoid or minimize the costs of covering eating disorders treatment. For example, many private employee benefit plans, which cover most Americans and adolescents, place greater restrictions and limitations on mental illnesses to reduce health care costs. Some of these restrictions include lower caps on mental health care than on physical health care, limits on the number of covered therapy sessions, days of residential or inpatient treatment, and dietitian appointments and lower “life” and annual maximums (Law and Inequality 2014; 31:411).

Some Help from Mental Health Parity Laws

Nearly every state has mental health parity laws, particularly those aimed at coverage for alcoholism and other chemical dependencies. As a result, some positive changes have occurred in states such as New Jersey and California. In a well-known California case, the Ninth Circuit Court decided that residential treatment was medically necessary for eating disorders and therefor [must] be covered under the California parity law despite an argument from Blue Shield that there is no exact equivalent of residential treatment for physical illness (Harwick vs. Blue Shield of California. 686F.3d 699, 703 (9th Cir 2012).

The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010, and its constitutionality was upheld by the Supreme Court in June 2012. The ACA prohibits insurance companies from denying coverage to people with preexisting conditions and mandates that individuals purchase insurance or incur a tax penalty.

But what of eating disorders? The current ACA leaves significant potential treatment gaps for patients with AN, BN, and feeding and eating disorders not otherwise classified. To attempt to fill those gaps, the Eating Disorders Coalition advocated for legislative reform through the Federal Response to Eliminate Eating Disorders Act of 2013, better known as the FREED Act. H.R. 2010. This act, currently in the Subcommittee on Health, Employment, Labor, and Pensions, would amend the Public Service Act (PHSA) and would require that “any insurer that provides health coverage for physical illnesses provide coverage for eating disorders: and require insurers “to follow standards of care as written in the Practice Guidelines for the Treatment of Eating Disorders by the American Psychiatric Association.” Insurance companies would be required to cover treatments including residential care, long-term therapy, and dietitians’ appointments. According to the Coalition, the FREED act would provide funding and direction to the National Institutes of Health for research and surveillance, provide for education and prevention activities, and improve access to treatment of eating disorders by requiring coverage of eating disorders be consistent with coverage of medical/surgical benefits.

Under the FREED Act, coverage would be available not only to patients who meet the strict criteria for AN and BN but also to those with other eating disorders. Thus, patients with binge eating disorder (BED) would also be eligible for coverage. If passed, the bill would ensure that treatment will be accessible to low-income Americans by including eating disorders treatment to services already covered by Medicaid.

Eating Disorders Parity

The individual states can require private insurers to cover eating disorders on the same bases as other health conditions. Beginning this year, mental illness and substance abuse services must be included in the essential benefits packages sold to individuals and small businesses. Ten states require private insurers to cover treatment for AN and BN on the same basis as other mental health conditions (CA, CT, DE, MA, MD, MN, NJ, VA, VT, WA). Eighteen other states do so in a more limited way, in that parity is only required in certain types of health plans (for example, state employee or group plans), according to the National Women’s Law Center Health Care Report Card (http://hrc.nwlc.org/key-findings) .

In the Meantime

While proposed legislation slowly progresses and eating disorders coverage parity gradually spreads to additional states, two experts offer some guidelines to help reduce the chances of having insurance coverage denied. According to Lisa Kantor, an attorney with Kantor& Kantor Law, and a well-known advocate for improved insurance coverage for patients with eating disorders, here are several steps to take. Before admission for treatment, patients and parents should request a copy of their insurance policy. One way that a treatment facility can be more proactive during admissions or after a denial of service is to send in all medical and treatment record to the insurance company on time and before any utilization review or appeals, and to have a patient’s records in front of them during utilization reviews. Treatment should be documented according to the American Psychiatric Association’s Clinical Practice Guidelines. Detailed notes of all conversations should be made and confirmation of all conversations should be in writing, including recording the name and number of the person with whom they spoke at the insurance company, the time on the phone, was the call transferred from one department to the other, and so forth. It’s also important, she notes, to document whether the insurance company has a qualified doctor conduct the review or if it is reviewed by a claims representative.

Dr. Arnold Andersen, a member of EDR Editorial Board, also has published some excellent guidelines to follow when coping with difficulties getting coverage (see “Ethical Conflicts in the Care of Anorexia Nervosa Patients,” in the March-April 2008 EDR ; see archives on this website; also see Principles of Inpatient Psychiatry, edited by Fred Ovsiew and Richard L. Munich, Wolters-Kluwer/Lippincott Williams & Wilkins, 2009)

Dr. Andersen suggests that patients read their policies and understand what is covered and what is not, and stresses that it is also important to know the individual state’s law. California is a good example. Coverage is mandated by California Assembly Bill 88, the mental health parity law, which now specifically includes treatment for patients with AN and BN. Other suggestions include keeping excellent records, including copies of all correspondence, letters and emails, including times, dates, names of persons contacted, telephone, fax, and e-mail messages.

Dr. Andersen writes that if treatment is denied, the decision should be appealed by phone and a letter written immediately to the medical director of the insurance company, stressing that if the patient’s needs are not satisfied, the state insurance commissioner, the media, or an attorney will be contacted. Lisa Kantor advises that while any legal action is pursued, it is important for the patient to remain in treatment.

Other resources may also be available. Dr. Andersen notes that community mental health agencies have sliding fees, and medical schools and university centers sometimes provide low-fee clinics staffed by psychiatric residents in training who are supervised by faculty members. If the treatment center is funded partly by county, state, or federal funds, the center may be required to make appropriate care available.

Free clinical trials and research programs can also be found on the Internet. Check the websites of the National Institute of Mental Health, the Academy of Eating Disorders, the clinic at the New York State Psychiatric Institute, and the American Academy of Child and Adolescent Psychiatry. Finally, scholarships may also be available for eating disorder treatment, according to Lisa Kantor (see box), as well as at the Clinical Trials.gov web site, where all trials are to be registered.

A few places to check for scholarships

http://www.mannafund.org/
http://www.kirstenhaglund.org/
http://www.freedfoundation.org