Improving Coverage for Eating Disorders: A Long, Slow Process

As Eating Disorders Awareness Week 2016 approaches, a little progress has been made in the effort to improve insurance coverage for patients with eating disorders (see also the May/June 2014 issue of EDR on breaking down barriers to eating disorders treatment).

One bright spot in 2015 was passage of Missouri’s Senate Bill 145, which amended a standing state law by adding a new section relating to the treatment of eating disorders. While other states may have vague laws requiring treatment of eating disorders, Missouri’s is the first state to dictate that treatment for eating disorders must be covered by insurance companies, according to Kerry Dolan, who directs the legal advocacy program of the National Eating Disorders Association.

This action followed a six-year battle to get more comprehensive coverage for eating disorders treatment by recently retired Missouri House Representative Rick Stream. Stream’s daughter Katie died in 1995 after a long battle with bulimia nervosa; her potassium levels were so low that her heart stopped. Citizen advocate Annie Seal worked on the bill for 7 years.

When Missouri Governor Jay Nixon signed the bill in August last year, Missouri became the first state in the nation to establish specific parameters that insurance companies must follow under the Patient Protection and Affordable Care Act, or ACA. Missouri’s new law is the first in the country to fully define treatment that must be covered according to the “Practice Guideline for the Treatment of Patients with Eating Disorders, adopted by the American Psychiatric Association, which outlines medical and psychological care. It is not a mandate but defines coverage under Missouri’s current mental health parity law. One important portion of the new law is that weight will no longer be used as the sole criterion for approving treatment. It replaces the edict that insurers in the state cover treatment only when an individual reaches 80% of his or her ideal body weight. This percentage has been unhelpful for anorexic patients and more so for those with bulimia nervosa, who can maintain a healthy weight despite being unhealthy.

One Idea: A National Benchmark Plan

Proponents of improved health coverage for patients with eating disorders have endorsed adoption of a national benchmark plan that would address the inequalities currently existing in access to lifesaving treatment for people with eating disorders.

Under the current ACA, 10 states now require coverage for anorexia nervosa and bulimia nervosa on the same basis as other mental healthcare conditions. Eighteen states only require coverage for eating disorder treatment within individual health plans, such as plans for state employees and group health plans. The remaining states have no laws requiring coverage of eating disorders. The ACA also provided three positive steps: (1) people with preexisting conditions can no longer be denied coverage for care. Before this, many insurance companies standardly denied coverage to people with eating disorders, classifying their conditions as preexisting. (2) Patients can remain on their parents’ insurance policies until they reach age 26, which is a real boon since so many cases affect people in their teens and 20s. (3) More people may qualify for Expanded Medicaid (now available in 28 states).

Sarah Hewitt, JD, has proposed that the inequalities in eating disorder coverage can be remedied through the adoption of a national Benchmark system. The Health and Human Services Department declined to define mental health care as an “Essential Health Benefit” (EHB), shifting the burden to the states to set individual benchmarks for care. However, this year they will be required to review this decision, taking into account events and consequences during 2014 and 2015 (Law and Inequality 2013. 31: 411). Attorney Hewitt contends that significantly higher healthcare costs result when insurers delay or refuse coverage to people with eating disorders.

The case of Danielle Moles illustrates this principle. Long-term care in a residential psychiatric facility was prescribed after Moles was diagnosed with anorexia nervosa. Her eating disorder had progressed, leading to permanent damage to her digestive system, a miscarriage, a stress fracture in one foot and periodic seizures. Her insurer insisted that her treatment was not covered by her policy and only agreed to pay costs after delaying a decision for several years. By the time coverage began, Moles’ condition had significantly worsened. Had coverage began earlier, it was found that her treatment would have cost the insurer roughly $80,000 instead of the $500,000 to $750,000 they eventually paid. The patient estimated that she had spent $150,000 out of packet for her4 care. (Michael Ollove, Parity for Behavioral Health Coverage Delayed by Lack of Federal Rules; http:/www.pewstates.org/projects/stateline/headlines/parity-for-behavioral-health-coverage-delayed-by-lack-of-federal-rules-85899433333)

Including all DSM-5 Recognized Eating Disorders

One step the Department of Health and Human Services could take would be to include all DSM-5 recognized eating disorders, including ED-NOS, into the category of “mental illness” in the EHB. As Hewitt indicates, such a national benchmark would finally guarantee that sufferers of all types of eating disorders received coverage for the long-term and comprehensive care needed for their recovery.

(Note: At the 2016 iaedp Symposium on Amelia Island, FL, Los Angeles-based attorney and eating disorders advocate Lisa S. Kantor, Esq. will present a preconference training session on “Advocating for Patients in the Current Legal and Regulatory Landscape.” The session is scheduled on February 17, from 9am to 12 noon.)

— MKS