Does Insurance Cover Eating Disorder Treatment?
Does insurance cover eating disorder treatment? Well, the answer to that is not straightforward. While the Affordable Care Act of 2010 improves overall access to healthcare, many gaps still exist within health insurance.
Many insurance companies are not properly educated on eating disorders, especially within public health plans such as Medicare and Medicaid. However, they are the ones who provide coverage and resources. In addition, some insurance companies have specialized eating disorder departments.
If all insurance companies had a specialized eating disorder department, it would likely make eating disorder healing more accessible through healthcare. Unfortunately, we’re still working toward that.
Let’s talk a little bit more about this topic so we can answer your question, does insurance cover eating disorder treatment?
The Overview: Eating Disorder Gaps in Insurance
The bottom line is that insurance is still not inclusive enough to completely cover or understand the needs of people with eating disorders and even related mental health conditions. For example, some major insurance gaps include:
Limited Coverage for Residential Treatment: Insurance plans may have limitations on coverage for residential or inpatient treatment, which can be crucial for severe cases of eating disorders.
High Out-of-Pocket Costs: Even with coverage, individuals may still face significant out-of-pocket expenses, such as copayments, deductibles, and coinsurance.
Limited Provider Networks: Insurance plans may have a restricted network of providers, making it challenging to find specialized professionals experienced in treating eating disorders.
Preauthorization Requirements: Some insurance plans require preauthorization for certain treatments, which can cause delays in getting timely care.
Coverage Exclusions: Certain types of therapies, such as holistic or alternative treatments, may not be covered by insurance.
Lack of Coverage for Long-Term Care: Extended or ongoing treatment beyond a certain duration may not be covered adequately, leaving individuals without support for long-term recovery.
Challenges with Medical Necessity Criteria: Insurance plans may use strict criteria to determine medical necessity, potentially leading to denials for coverage.
Denial of Claims: Insurance companies may deny claims for eating disorder treatment, requiring individuals to appeal the decision, which can be time-consuming and stressful.
Stigma and Lack of Understanding: There may be a lack of understanding or stigma surrounding mental health issues, including eating disorders, leading to inadequate coverage.
The Specifics: Major Holes in Insurance Coverage
While there are many challenges with insurance coverage for eating disorders, here’s a breakdown of some of the most problematic issues we’ve continued to see.
BMI is Still a Part of Insurance Coverage
While the AMA adopted a new policy clarifying the role of BMI in medicine, it’s still part of the overall health “picture” taken into consideration. The AMA press release explains:
“The AMA also recognizes that relative body shape and composition differences across race/ethnic groups, sexes, genders, and age-span is essential to consider when applying BMI as a measure of adiposity and that BMI should not be used as a sole criterion to deny appropriate insurance reimbursement.”
In addition, even though several treatment centers are moving away from BMI, insurance companies often look for a low Body Mass Index (BMI) as the primary need for a residential level of care, and weight is often still used as the standard for health and stability.
The healthcare system, and insurance, also perpetuate this stigma that eating disorders are most severe when you are in a smaller body, have medical complications, and engage in eating disorder behaviors with similar symptom use.
This is only one of the many biases within insurance. If treatment is authorized for a patient, insurance often denies coverage for continued treatment or recommends a lower level once they reach a certain BMI.
Lack of In-Network Eating Disorder Providers Limits Support
Due to the limited number of specialized professionals with eating disorder experience in the field, as well as the limitations from insurance, it is often difficult to find outpatient therapists and dietitians who take your insurance.
Professionals such as therapists and dietitians are only able to practice in the state(s) they are licensed, providing even fewer who are in-network. Finding providers with shared identities who take insurance can be even more difficult.
What’s more, in Medicare plans, Medical Nutrition Therapy is not covered for eating disorders, and this is also the case with some Medicaid and commercial plans.
California law (Senate Bill 64) requires Medical Nutrition Therapy to be an included benefit within health insurance policies. However, it is only required that Medical Nutrition Therapy is provided for a diagnosis of Diabetes.
While many plans in California do not exclude Nutrition Therapy for eating disorders, there are some plans that do. This results in an overall lack of treatment accessibility.
Mental Health Support is Not Fully Covered
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that requires group health plans and payers to provide mental health/substance use disorder benefits. These benefits are required to have equal coverage to services provided by medical benefits.
However, medical issues are often treated in a hospital or office; the MHPAEA may limit mental health coverage to the same treatment options (inpatient or outpatient), especially within public health plans such as Medicare and Medicaid. This then excludes any other levels of care that are often necessary for eating disorders, such as residential, and many other services are excluded under Medicare.
Insurance is Expensive
Through the Insurance Marketplace, discounts and tax premiums may be provided, depending on your income, family size, and other circumstances. However, if you make a certain income, you may not qualify for discounts on the health plans offered through the Marketplace. This often makes the available plans too costly. If you’re eligible for discounts, but are looking for a plan outside of the Open Enrollment Period, the discounts won’t be available.
Medicaid can be applied for year-round. However, a Medicaid coverage gap exists. If your state hasn’t expanded Medicaid, your income is below the federal poverty level, and you don't qualify for Medicaid under your state's current rules, you won’t qualify for either health insurance savings program: Medicaid coverage or savings on a private health plan bought through the Marketplace.
That leaves people in a situation in which it is extremely difficult, or not possible, to obtain health insurance and also ineligible for financial assistance with their health insurance through Medicaid or the Marketplace.
Ten states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—have not expanded Medicaid eligibility under the Affordable Care Act to individuals with incomes up to 138% of the federal poverty level.
You can read more about this on healthcare.gov.
Get Help Navigating Insurance Coverage and Eating Disorders
When it comes to the confusing nature of insurance plans, it is often overwhelming, expensive, and under certain circumstances, not always possible to find the right (or any) insurance plan - whether it’s through an employer, the Insurance Marketplace, or elsewhere. Many people also do not know what is covered within their plans and what to look for when it comes to treatment coverage.
To help you understand your benefits and how to get the help you need, we have a few other helpful resources:
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