NEDA TOOLKIT for Parents
Ask the insurer whether they will “flex the
benefit.” Negotiate with the treatment center about
the cost of treatment.
Flexing benefits means that the insurer applies one
type of benefit for a different use. For example,
medical benefits might be “flexed” to cover some
aspect of mental health treatment— usually
inpatient treatment. Also, inpatient benefits might be
flexed (traded) to substitute intensive outpatient
care for inpatient care—for example, 30 inpatient
days for 60 intensive outpatient benefit days.
Substance abuse (also called chemical dependency)
benefits might be traded for additional benefits to
treat the eating disorder if the beneficiary thinks
he/she will never need the substance abuse benefits
available under his/ her coverage. There is a clinical
rationale for doing this: if the eating disorder is not
treated appropriately from the outset, the insurer
risks incurring additional and higher costs for patient
care in the future because further hospitalization
and treatment may be needed. By flexing inpatient
medical benefits or trading inpatient days for
outpatient days to obtain more days of mental
health treatment, future and possibly higher
healthcare expenses might be avoided. While
insurers are not obligated to do flex benefits, they
may respond to a sound, logical argument to do so if
it makes good sense from both a business and
patient care perspective in the longer term. If you
can support this argument with your doctors’
recommended treatment plan and clinical evidence
from practice guidelines and an evidence report, the
insurer may agree.
Our survey of treatment centers indicates that some
treatment centers have a sliding fee scale and may
adjust the treatment charges or set up a payment
plan for the patient’s out-of pocket costs.
Discuss with the insurer how existing laws
and clinical practice standards affect your
situation. Educate yourself about how the state’s mental
health parity laws and mandates apply to the
patient’s insurance coverage. Also ask the insurer if it
is aware of evidence reports on treatment for eating
disorders and guidelines like the American
Psychiatric Association’s clinical guidelines for
treating eating disorders: www.psych.org. Ask what
role the evidence plays in the decision about
benefits. As a last resort, some patients or their
advocates may also contact the state insurance
commissioner, state consumer’s rights commission,
an attorney, the media, or legislators to bring
attention to the issue of access to care for patients
with eating disorders.
If the patient is employed or in a union, consider
asking the employer (or its human resources
manager) or union representative to negotiate with
the insurer about aspects of the coverage policy that
seem open to interpretation. As a client of the
insurance company, the employer is likely paying a
lot of money to provide benefits to employees (even
when employees pay part of the insurance
premiums). Because insurance companies want to
maintain good business relationships with their
clients, the employer may have more influence than
the patient alone when negotiating for
reimbursement. Many patients or families of patients
are afraid or embarrassed to discuss bulimia or
anorexia with an employer. Remember that legally, a
person cannot be fired and insurance cannot be
dropped solely because of having an eating disorder
(or any other health condition).
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