Understanding Insurance Coverage for Eating Disorder Treatment

March 10, 2023

Oona Hanson

When you or a loved one are struggling with an eating disorder, the last thing you want to do is navigate the convoluted world of health insurance. But unfortunately, confirming coverage is often one of the first steps toward getting the care you need. The good news is that by understanding your benefits, learning some key terminology, and understanding the landscape of insurance for eating disorder treatment, you can make the process a lot less overwhelming.

It’s complex, but it’s manageable. Let’s break it down, piece by piece.

How Do I Know What Eating Disorder Coverage I Have, if Any?

Insurance coverage for eating disorder treatment varies widely by insurance carrier, and even within an individual carrier, specific types of plans can differ significantly—whether you have a PPO or HMO, for instance, will determine how you access eating disorder specialists covered by your plan. And even within a particular plan, there may be several levels of coverage, such as Bronze, Silver, Gold, and Platinum. These “metal tier” categories generally indicate not what is covered but how much you will be expected to pay out of pocket when you use services.

To complicate things further, depending on your insurer, your mental health benefits may be managed by another company entirely. For example, you may have Anthem Blue Cross insurance, but your mental health services (often called “behavioral health”) may be administered by Beacon Health Options. If you have questions about your eating disorder treatment coverage, Nina Ho, Equip’s Director of Business Development, recommends you call the “Member Services” number on the back of your insurance card.

Does Medicaid Cover Eating Disorder Treatment?

Medicaid is both a state and federally funded program, so options vary based on where you live. Your state government will have a website that provides information specific to your area (Google “Medicaid” and your state to find the relevant website). For those who have MediCal (the name for Medicaid in California), the California Healthcare Foundation offers helpful information on understanding that state’s unique programs.

With Medicaid, treatment for an eating disorder diagnosis falls under the category of “specialty mental health,” which is administered separately by county. However, because eating disorder treatment may involve both mental health and physical health services, coverage may be divided between the county and state’s managed care organization that administers your Medicaid benefits. While this sounds (and is) complicated, you can gain clarity by contacting your state’s Medicaid agency to understand your specific benefits for eating disorder treatment.

How Do I Find In-Network Treatment Programs and Providers?

Equip’s Nina Ho suggests families begin by accessing the Provider Directory on their insurer’s website and searching for the types of professionals you are seeking in your area. She adds that most insurers also have what’s called a “Center of Excellence” network, where they’ll highlight vetted specialty providers that meet high-quality standards. For more personalized support, remember you can always contact your insurer’s Member Services or Case Management office.

If you’re looking for an eating disorder treatment program rather than individual practitioners, you’ll need to check with your insurance provider to see if the program you want is covered. Equip is in-network with most major insurance carriers, and when you contact us to inquire about treatment, we’ll check whether or not you’re covered under your plan. Currently, we are covered by 10+ commercial plans (including Aetna, Cigna, Anthem Blue Cross Blue Shield, Optum, United Healthcare, and more) as well as Medicaid in California.

Note that for treatment at a higher level of care (HLOC)—such as a partial hospitalization program (PHP), residential treatment, or inpatient hospitalization—you will likely need what is called “prior authorization” for treatment, even when those programs are in-network with your insurance. The admissions department at the treatment center will explain the specific process required for your case.

What If a Provider Is Not Covered by Our Insurance?

Many mental health professionals, including highly trained eating disorder treatment providers, may be “private pay,” meaning they are not in-network with any insurance providers. If your insurance coverage includes out-of-network benefits, you may be able to get partial reimbursement; if so, you pay the full cost of the services up front and then submit invoices and any other required paperwork to your insurance company.

In some situations, a treatment provider or program may be able to negotiate what’s called a “single case agreement” with your health insurer, particularly if you do not have any in-network options available in your area. A single case agreement, or SCA, is a type of contract that covers a specific patient receiving a service for a predetermined amount of time at an agreed-upon rate.

What If Insurance Coverage Is Ending, but We Still Need Care?

It’s an all-too-common story for those in eating disorder treatment: insurance declines to continue coverage even though the patient still needs more support. Some insurers may completely end coverage, while others may require that a patient steps down to a lower level of care. This is an issue because getting continued care at the appropriate level is often a cornerstone to relapse prevention: research shows that relapse rates are lower when patients are discharged at a higher BMI, which often requires lengthier treatment, and that staying in treatment longer (and long enough to create a relapse prevention plan) lowers risk of relapse. Equip treatment is generally covered for one year by most insurance providers.

Occasionally the treatment program or provider can negotiate an extension of coverage, often by providing data on the individual’s eating disorder symptoms. Sometimes this request is called a “doc-to-doc” or “peer-to-peer” appeal, in which the patient’s medical provider speaks directly with a medical provider at the insurance company. In some cases, the patient or their family may also directly appeal to the insurance company, explaining firsthand why they need continued care.

When in Doubt, Go Old-School: The Phone Is Your Friend

While insurance company websites offer a wealth of “self-serve” information, it’s often difficult to get definitive answers about your specific situation from the internet alone. To get a fuller understanding of your coverage and benefits, talk to a live person who is trained to guide you through the process. Of course, it can be challenging to carve out time to make these calls—especially if you end up on hold or need to be transferred to other departments—but this effort will likely save you time, hassle, and even money.

When you talk to someone at your insurance company, take notes in a journal or digital notes app; whenever possible, get the name and direct extension of the people or departments you find most helpful so you can reach them again when you have further questions.

Of course, even with this knowledge, sometimes you’ll still encounter barriers to treatment: your insurer might deny coverage for your or your loved one’s eating disorder, or you might not be able to afford treatment even with the help of coverage (due to deductibles, copays, coinsurance, etc). These situations can be both heartbreaking and frustrating, but you still have options. For instance, there is a formal process for appealing a health plan’s decision, and there are organizations that offer financial assistance for eating disorder care, like Project HEAL.

Battling an eating disorder takes a lot of patience and grit—and you may find yourself needing that same resolve while navigating your health insurance plan. Through it all, remember that recovery is possible, and it’s worth fighting for.

Citations:

Treatment & Recovery