NEDA TOOLKIT for Parents
Navigating and Understanding Health Insurance Issues
This guidance is intended to assist people looking for help when accessing care and when insurance denies
coverage for treatment of eating disorders. The information here was compiled from research by ECRI Institute
and the experience of parents and treatment providers who have had experience obtaining coverage for eating
disorders care.
In a separate document are sample letters to adapt to
various insurance situations related to obtaining
appropriate care. This information has not been
prepared by attorneys and is not intended as a legal
document. This information does not guarantee
success. If you have suggestions, feedback, or personal
additions to share (e.g., submit a sample letter you’ve
used with your insurance company with all identifying
information removed), please email National Eating
Disorders Association at
info@nationaleatingdisorders.org with “Insurance
Issues” in the subject line.
The National Eating Disorders Association fields many
questions every day that focus on how to gain access
to care and navigate insurance issues. While there is
little argument that early intervention offers the best
chance for recovery, insurance and the healthcare
system can pose barriers to accessing prompt,
comprehensive treatment.
Accessing the full benefits a patient is entitled to
under his/her health plan contract requires
understanding a few things about all the factors that
affect access to care, coverage, and reimbursement.
Navigating the system to find out what the patient is
entitled to receive also takes a lot of energy. While
parents can legally act on behalf of children younger
than age 18, they need permission from a child older
than age 18 to act on his/her behalf.
Because treatment usually involves both mental
healthcare and medical care aspects, a well-rounded
care plan must address both types of care. The overall
healthcare system has long treated medical care and
mental healthcare separately. The result of that care
model is that health insurer benefits plans have often
followed suit by separating mental health benefits
(also called behavioral health benefits) from medical
benefits. This split has created great difficulty for
people with an eating disorder because they need an
integrated care plan. Ways to steer through these
difficulties are offered here in an 8-step plan.
Another issue is the level of benefits for mental
healthcare. For years, many health plans provided few
or no mental health benefits. When they did, most
subcontracted those benefits through “mental health
carve-out” plans. Such plans are administered by
behavioral health service companies that are separate
from health plans. This approach made well-rounded
care by a multidisciplinary team very difficult to
achieve. Even when a psychotherapist and medical
doctor want to integrate services and case
management to treat the patient as a whole person,
the healthcare delivery system in the United States
poses barriers that prevent that from happening.
For example, when a service is provided by a doctor or
facility, a billing code is needed to obtain
reimbursement for services. Certain rules and
regulations govern how services must be coded and
who can perform those services. Different types of
facilities and different healthcare professionals must
use codes that apply to that type of facility and health
professional. Also, if codes don’t exist for certain
services delivered in a particular setting, then facilities
and health professionals have no way to bill for their
services. Codes used for billing purposes are set up by
various entities, such as the American Medical
Association, U.S. Medicare program, and the World
Health Organization’s International Classification of
Diseases. Thus, even a patient with good health
insurance may face barriers to care simply because of
the way our healthcare system is set up.
The system is slowly changing. Sporadic improvements
have come about as a result of lawsuits and state
legislation prompted by individuals, legislators,
clinicians, support groups, and mental health
advocacy groups. The U.S. federal government and
most U.S. states have passed some form of mental
health parity law. Generally these laws require
insurers to provide benefits for mental healthcare that
are equivalent to benefits for medical care. These laws
do, however, vary widely in their provisions.
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