The Cost of Healthcare’s Failure to Deliver Access to Eating Disorder Healing
Written by Alexa Grayson, Project HEAL Insurance Navigation Program Manager
In the Minnesota Journal of Law & Inequality, Sarah Hewitt writes: "both public and private health insurance plans are designed to stringently limit coverage of eating disorders in two ways: by treating mental illnesses differently from physical illnesses, and by setting conservative criteria for qualification."
Insurance Coverage is a Barrier to Healing
Eating disorders pose serious risks to both physical and mental health, requiring specialized treatment for recovery. Yet, the financial burden of seeking higher levels of care treatment (i.e. residential, partial hospitalization, intensive outpatient) for eating disorders can be overwhelming. The barriers to accessing treatment are evident, with costs reaching up to $2,000 per day — that’s upward of $60,000 per month without insurance. For those without financial resources or insurance coverage, finding treatment can be beyond onerous.
Despite the clear evidence that eating disorders are physically and mentally life-threatening, insurance coverage for treatment often falls short. While many commercial insurance plans include mental health coverage for residential and inpatient care, which encompasses eating disorder treatment, government-funded plans are different. These plans, like Medicaid and Medicare, generally lack comprehensive coverage for these levels of care, typically covering only inpatient and outpatient. This leaves a huge gap in the spectrum of care, making it much more difficult for those on government-funded plans to find healing and costing the government millions.
Even for those who have insurance benefits, coverage is not guaranteed. In many cases, insurance policies require prior authorization, also known as precertification, for higher levels of care. This authorization process is further complicated by the need for ongoing clinical reviews to prove “Medical Necessity Criteria”, showing that the patient’s condition warrants continued treatment. From a payer’s perspective, this process, known as utilization review, allows them to monitor and manage care, and control costs.
If you have the included benefits and financial resources, you then must find an in-network program, and then get your authorization. There are so many barriers, and even if all the above goes through, insurance still may deny care prematurely or in full. When it comes to eating disorders, society has learned to associate them with thin, white, cis-women with higher socioeconomic status, who struggle with what might be most familiar to people when thinking of an eating disorder – anorexia or bulimia. The healthcare system, and insurance, also perpetuates 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.
BMI is B.S., but insurance uses it anyway.
Even though several treatment centers are moving away from Body Mass Index (BMI) towards Ideal Body Weight and Target Body Weight, insurance companies often look for a low BMI as the primary need for residential or inpatient levels of care.
BMI, a flawed and outdated health standard for health and stability, was created in the 1800s to measure what was seen as the “ideal” for the “average” white man. BMI does not account for differences across multiple groups, failing to consider race, ethnicity, sex, gender, age, neurodivergence or disabled bodies. BMI also perpetuates the misconception that eating disorders are most severe in smaller bodies with specific, correlated behaviors. This bias de-prioritizes coverage for eating disorders that may not align with what people might think of as a “stereotypical” eating disorder; these include Other Specified Feeding & Eating Disorder (OSFED), Atypical Anorexia, Binge Eating Disorder — which are the most prevalent among eating disorders — and Avoidant-Restrictive Food Intake Disorder (ARFID). These diagnoses can be equally severe; however, an individual’s BMI, weight, or medical complications may not fall into the assessment criteria for needing a higher level of care, and therefore they’re less likely to have that care covered by insurance.
If precertification is granted for admission, insurance may still deny further coverage once a patient gets to a certain BMI, showing they are “stable”, per insurance criteria. This is especially true for inpatient, which is often approved when showing a need for a higher level of medical monitoring than residential.
Steps Toward Improvement
To improve insurance coverage for mental health, The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) was created: 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, partial hospitalization (PHP) and intensive outpatient (IOP), and many other services are excluded under Medicare.
In an article published by The Professional Counselor journal, Medicare gaps in mental health coverage were highlighted. “The Medicare program has not updated its mental health provider licensure standards since 1989” and is still unaccountable to the Mental Health Parity and Addiction Equity Act. Some Medicare gaps include limited available in-network options, a 190-day lifetime max for inpatient mental health stays, no residential coverage, limitations in available PHP/IOP programs that must be hospital-based, and no coverage for Medical Nutrition Therapy for an eating disorders diagnosis. For those with Medicare who do not need inpatient medical stabilization and would not qualify for inpatient due to being at BMI that is considered “stable”, this means without residential benefits, outpatient may be the only covered option.
Recognizing the gaps in insurance coverage, organizations like Project HEAL exist to support individuals who lack the resources to access necessary, equitable, and deserved treatment. Like residential and inpatient, intensive outpatient (IOP) is often covered — if a client is insured, with financial resources, and has an in-network treatment center within their geographic location. Virtual IOP also exists. However, many insurance plans do not cover telehealth services, which limits the treatment centers they can attend. Preauthorization is often still a requirement for intensive outpatient, though there are some payers, such as Aetna and Cigna, who will not require IOP authorization to admit or stay in treatment.
Navigating insurance can feel impossible.
Navigating the cost structure of insurance plans adds another layer of complexity. Premiums, deductibles, out-of-pocket maximums, and copays all contribute to the financial burden faced by individuals seeking treatment. These upfront costs can be very expensive, especially for those without financial resources. Once you meet your deductible, insurance starts kicking in, and you begin paying copays. There is then an out-of-pocket maximum (OOPM), which is the maximum amount you will have to pay in a calendar year before insurance covers everything 100%. An OOPM is often upwards of $5,000 or more.
The glaring financial barriers and insurance obstacles individuals encounter when seeking eating disorder treatment draw attention to the demand for significant reform. It's evident that mere reform isn't enough — we require a comprehensive change of system that goes beyond insurance coverage. This necessitates a paradigm shift towards size inclusivity, abandoning antiquated measures like BMI, and extending coverage to include all life-saving treatments.
I envision a future where accessing treatment isn't for the “privileged few.”
Alexa Grayson (she/her) joined the Project HEAL team in 2020 as a national volunteer and later joined staff as the Program Manager for the Insurance Navigation Program. Alexa brought her experience in insurance and mental health to help Project HEAL’s directors develop and implement the Insurance Navigation Program.
Alexa graduated from Pennsylvania State University in 2014 with a Bachelor of Science in Psychology and Minor in Business Administration. In 2016, she received her Master of Education in Counseling Psychology from Temple University.
Alexa brings lived as well as professional experience from a variety of settings, including private practice and higher level of care eating disorder and substance use programs. Most of her clinical experience comes from working with folks of all genders who struggle with eating disorders. She has also worked with those experiencing perinatal mood and anxiety, grief, chronic pain, substance use and trauma. Alexa has held positions such as individual and group therapist, admissions clinician, and those involving extensive work in insurance and utilization review.