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Getting Coverage for Eating Disorders Treatment

Reprinted from Eating Disorders Review
By Pauline Powers, MD

Finding the medical coverage treatment of an eating disorder can be a real challenge, but having a plan makes it much easier to find the treatment you need.

1.Get an assessment so the diagnosis will be established. You will need an assessment so the disorder and its associated mental and physical problems can be properly diagnosed and documented.

2. Do you have mental health benefits? If you have insurance, you may also have mental health benefits. Often these benefits include an amount for hospital or residential treatment and an amount for outpatient treatment as well. Nearly all health policies include major medical benefits, which are typically much greater than the mental health benefits. Some companies provide Employee Assistance Programs (EAPs), and appropriate care is sometimes available through these programs. Read the booklet that comes with your insurance policy or call the phone number on your insurance card and ask about your benefits.

3. Obtaining your benefits. Although you may have what appear to be adequate benefits, the next issue is whether or not you can use them to obtain appropriate care. The three major types of health insurance policies are: indemnity, preferred provider organizations (PPOs), and health maintenance organizations (HMOs). Very few people have indemnity policies, but they are usually the most comprehensive and have the greatest flexibility. PPOs are usually much more flexible than HMOs. There is usually a deductible (a portion of the charge from the hospital, residential treatment center, or care provider that you pay). And, especially in the case of HMOs, there are reviewers (often untrained clerical personnel) who decide how much of your benefits will be available to you when a diagnosis is made. This decision may be made based on idiosyncratic rules that do not reflect current evidence-based treatment approaches and often do not reflect the consensus of professionals.

4. Determine health-care providers. It is also important to determine what the treatment center or care provider will need to help you obtain those benefits. This is not always easy to determine in advance. Ask your insurance company to send you a list of providers. If your professionals are on the list, call these professionals and let their office personnel know the results of your assessment, including the diagnoses, the type of treatment recommended and where it will be given, and estimated length of treatment.

If Your Provider Does Not Provide the Recommended Treatment

1. If your insurance benefits do not match the recommended treatment:
For example, if you have anorexia nervosa of the binge/purge type, and residential treatment is recommended for 60 days, your insurance benefits may only cover 10 days of residential treatment. In this case, first try calling your insurance company and ask to obtain your major medical benefits. It is logical to turn to major medical benefits because the semi-starvation that results from anorexia nervosa is a physiological complication and if untreated will likely result in hospitalization on a medical floor in a general hospital, which will ultimately be very expensive.

Eating disorders are medical illnesses and it is worthwhile to mention this fact to your insurance company. Typically, however, this will not result in any change on their part. The next step is to contact the personnel department of the company that purchases the insurance. Remember that insurance coverage is called a "benefit" but in fact it is a part of the compensation to the worker who has the insurance policy.

Insurance coverage is not a gift from the employer. Furthermore, the insurance company is supposed to hold the funds paid by the employer on behalf of the employee and dispense them according to rules set down by the employer. Thus, the employer can decide to fire the insurance company (and ultimately the HMO or PPO).

The important point to remember is that it is actually your employer (or the employer of the person who has the insurance) who has power over what benefits are provided from the HMO or PPO. Thus, your personnel department can be helpful. You may find that the insurance company blames the employer or the employer blames the insurance company. Since the employer pays for the insurance benefits (which can include hiring an intermediary HMO), ultimately (although not immediately), the employer can choose to change insurance companies.

2. Despite your best efforts, your insurance company and personnel department are not helpful.
Although it is tempting to give up at this point, other steps can be taken. First, let your insurance company know that you have decided to call the insurance commissioner, and then call him. When you speak with the commissioner, tell him what has been recommended, what steps you have taken to obtain treatment, and the results of these attempts. Follow this up with a letter explaining the difficulties. Keep a copy of this letter for your files. If the insurance commissioner is not helpful, the next step is to contact your senators and congressmen and congresswomen. If they aren't helpful, contact the governor.

3. When efforts to obtain care by contacting your legislators and the governor are not effective:
Self-help groups may be the answer. For example, the Eating Disorders Awareness Program may be helpful (603 Stewart Street, Suite 803, Seattle, WA 98101). National information and the referral hotline is: 800-931-2237. The office number is 206-382-3587.

4. Try creative solutions.
Some families have been able to access help by contacting their attorney if benefits are available through an insurance company but the benefits are not available. Other families have gotten their insurance companies to make appropriate decisions by contacting the local newspaper or magazines and describing their plight. Others have called local help programs on radio and television.

5. Determine if you can afford care if your insurance company will not pay for it.
Once you know what care is recommended, who should provide it, and where this care should be provided, find out the stated total charges from the institution and/or professionals providing the care. Assess your own financial resources and negotiate a fee/charge you can afford.

If You Have Medicare or Medicaid Benefits

Although many hospitals and treatment centers accept Medicare and/or Medicaid, many have no staff members with experience in treating eating disorders. If the treatment center is a mental health center, which is funded in part by county, state, or federal funds, you can sometimes ask that appropriate care be provided and sometimes there are personnel at the center who are familiar with the treatment of eating disorders.

When You Have No Money or Insurance Benefits

Treatment programs do exist for people who have no money or benefits, but they are often hard to locate. Some agencies that receive public funds do provide treatment, and sometimes that treatment is outstanding. Another way to obtain treatment is through community agencies—sometimes treatment is provided at no cost or with a sliding scale fee. Counseling centers and student health services are another option if your patient is a student on a college or university campus. To get treatment at these locations, you usually pay a student health fee with your tuition.

Many departments of psychiatry within medical schools have low-fee clinics run by psychiatric residents (medical school graduates who have had two or three years of their psychiatric training and are supervised by experienced faculty members). Call the department of psychiatry within the medical school and ask if they have low-fee clinics run by residents and if they will accept a patient with an eating disorder. Be sure to ask about sliding-scale fees and ask about what supervision the medical resident has available to him or her.

No-Fee Research Treatments

Sometimes treatment can be obtained through a research program. For example, periodically Columbia University in New York has openings for patients willing to be part of an ongoing research program for patients with anorexia nervosa. The program is the Eating Disorders Clinic at New York State Psychiatric Institute at Columbia Presbyterian Medical Center in New York City. To ask about the program, call the research assistant at 212-543-5739.

A research study may be underway at a college or university near you, and the newspaper may run announcements of these programs. It is important to remember that although there may be no fee for part of the treatment, there may be fees for certain non-research portions of the study, and there are inclusion and exclusion criteria.

Final Thoughts

Keep trying to get better and trying to locate people to help you. Although you will encounter many barriers to accessing appropriate professional treatment, if you are committed to recovering, it can usually be accomplished. Care providers themselves are energized when patients want to recover and can often help you find the help you need. Many primary care physicians and pediatricians are relentless in trying to find help for their patients and your interest in recovery will encourage them to help you.

Facts to Know When You Seek Insurance Coverage

1. Your eating disorder diagnosis
2. Other psychiatric disorders
3. Physiologic complications of the eating disorder
4. Level of care recommended:
outpatient, inpatient, partial hospitalization, intensive outpatient
5. Anticipated duration of recommended treatment
6. Professionals needed and their required expertise

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Additional Resources:

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