Understanding Insurance Coverage for Eating Disorder Treatment

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 necessary to get the care you need. The good news is that by 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 down some frequently asked questions, piece by piece.

Does my insurance cover eating disorder treatment?

The best way to understand what eating disorder treatment coverage you have is to contact your insurance company directly. You can call the “Member Services” number on the back of your insurance card, or search for services on your insurance’s online portal.

The reason it’s important to get direct answers about your specific coverage is because the answer can vary widely by your carrier and type of plan—whether you have a PPO or HMO for example. There may also be several levels of coverage, such as Bronze, Silver, Gold, and Platinum, that generally indicate how much you’ll be expected to pay out of pocket.

It’s also worth noting that depending on your insurer, your mental health benefits may be managed by another company entirely. When you contact your insurance about eating disorder treatment, they’ll be able to tell you if your mental health benefits live elsewhere.

Does Medicaid cover eating disorder treatment?

The answer (unfortunately) is, it depends.

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 (select your state here). For those who have MediCal (Medicaid in California), the California Healthcare Foundation offers helpful information on understanding that state’s unique programs.

If you have Medicaid, you’re probably familiar with the fact it has many intricacies. The best way to gain clarity is by contacting your state’s Medicaid agency to understand your specific benefits for eating disorder treatment.

Equip is currently covered by Medicaid in three markets, and we’re actively working to add more.

How do I find in-network eating disorder treatment?

Here are a few steps to help you find covered providers:

  1. Access the provider directory on your insurer’s website and search for the types of providers you’re seeking in your area (therapist, dietitian, physician, etc).
  2. Look to see if your insurer has a “Center of Excellence” network, where they’ll highlight vetted specialty providers that meet high-quality standards.
  3. Contact your insurer’s Member Services or Case Management office for more personalized support.

If you’re looking for an eating disorder treatment program rather than individual providers, the steps are a bit different. You should:

  1. Do your own research on which program and level of care you’re interested in (virtual vs in-person? Inpatient vs outpatient?).
  2. Contact both the program and your insurance provider to confirm if you have coverage.

Equip is in-network with most major insurance carriers. If you’re interested in pursuing virtual treatment at Equip for you or your child, you can contact us to see if we’re in-network with your health plan.

What is “prior authorization” for eating disorder treatment?

Another thing to be aware of is “prior authorization.” Prior authorization is when an insurance company requires your medical provider to first submit a formal request and receive permission from your insurance company before the service will be covered. For treatment at a higher level of care (HLOC)—such as a partial hospitalization program (PHP) residential treatment, or inpatient hospitalization—prior authorization is often required even if the program is in-network. The admissions department at the treatment center can explain what this process will look like for you.

What if a provider or program isn’t covered by my insurance?

The unfortunate reality is, quality eating disorder treatment programs or providers are still not covered by some health plans or may be “private pay” (meaning they don’t take insurance at all). If the treatment you want isn’t covered, you have two options:

  1. Partial reimbursement: If your insurance coverage includes out-of-network benefits, you may be able to get partial reimbursement. You would pay the full cost of the services up front, and then submit invoices to your insurance company.
  2. Single case agreement (SCA): 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 don’t have any in-network options available in your area. A SCA is a type of contract that means you will get coverage for a certain amount of time at an agreed-upon rate.

What if insurance coverage is ending, but I 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. Unfortunately, research shows stepping down before a patient is ready (particularly if they haven’t reached their target BMI) can increase relapse rates— which is why it’s important to try to stay in the appropriate treatment as long as you or your loved one needs it.

If you find yourself in this situation, know that it may be possible for you to extend coverage. You can ask your medical provider to explain the need for continued care, or even appeal directly to the insurance company, explaining why your family needs extended coverage.

At Equip, we seek insurance authorization for a full year to make sure patients achieve full recovery and are protected against relapse when they discharge.

When in doubt, the phone is your friend

It’s often difficult to get definitive answers about your specific situation from your insurance’s website alone. The best way to get a full understanding of your coverage and benefits is to talk to a live person who is trained to guide you through the process. Of course, these calls can come with their own challenges (needing to hold, being transferred, getting frustrated…), but this effort will likely save you time, hassle, and even money in the long run.

Here are some tips for when you do reach your insurance company by phone:

  1. Take notes in a journal or digital notes app.
  2. Get the name and direct extension of the people or departments you find most helpful.
  3. Reach back out to the same people you’ve already connected with if further questions pop up.

Sometimes you’ll still encounter barriers to treatment: your insurer might deny coverage, 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, you can try to appeal 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.

Equip is on a mission to ensure that everyone who needs eating disorder care has access to treatment that works. A big part of that mission is to make Equip a covered benefit for as many people as possible. That’s why we are constantly working to expand coverage.

Talk to a professional about getting treatment coveredOur team is here to talk you through your options with or without insurance in a free consultation.
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Oona Hanson
Family Mentor
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