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NEDA TOOLKIT for Parents Steps to maximize insurance benefits Educate yourself Read the other information in the Parent Toolkit to learn about eating disorders, treatment, current clinical practice guidelines, and how you can best advocate for and support the family member who has an eating disorder. Refer to the latest evidence-based clinical practice guidelines in this toolkit and have them in hand when speaking to your health plan about benefits. Be prepared to ask your health plan for the evidence-based information they use to create their coverage policy for eating disorders. Find out if your state has a mental health parity law or mandate and what the terms of that law or mandate are. Mental health parity simply means that your insurance company must not limit mental health and substance abuse healthcare by imposing lower day and visit limits, higher copayments and deductibles, and lower annual and lifetime spending caps than they do for medical care. The website www.bulimiaguide.org has detailed information about which states have mental health parity laws or mandates and what those laws and mandates cover. See the Eating Disorders Coalition for Research, Policy & Action web site for how to get involved in the effort to influence federal policy at: www.eatingdisorderscoalition.org. Get organized If a patient’s first encounter with the healthcare system is admission to an emergency room for a life- threatening situation with an eating disorder, whoever is going to deal with insurance issues on the patient’s behalf will need to get organized very quickly to figure out how to best access benefits. Patients who are seriously medically compromised will likely be in the hospital for a few days before discharge to outpatient care or a residential eating disorder center. Those few days are critical to negotiating reimbursement for the longer-term care. If the situation is not an acute emergency and you want to find a treatment center, consider whether you have authority to act on the patient’s behalf or whether the patient must give you written authority to act on his/her behalf. If a child is 18 years of age or older, parents will need the child’s written permission to act on the child’s behalf. Healthcare providers have forms that require signatures to allow free flow of communication and decision making. A spouse, partner, friend, or other person who wants to act on behalf of the patient will need to have the patient sign appropriate authorizations. Medical confidentiality is discussed later in this section. Read the patient’s entire insurance benefits manual carefully to understand the available benefits Obtain a copy of the full plan description from the health plan’s member’s website (i.e., the specific plan that pertains to the insured), the insurer or, if the insurance plan is through work, the employer’s human resources department. This document may be longer than 100 pages. Do not rely on general pamphlets or policy highlights. Read the detailed description of the benefits contract to find out what is covered and for how long. If you can’t understand the information, try talking with the human resources staff at the company that the insurance policy comes through, with an insurance plan representative (the number is on the back of your insurance identification card), or with a billing/claims staff person at facilities where you are considering obtaining treatment. If hospital emergency care is not needed, make an appointment with a physician you trust to get a referral or directly contact eating disorder treatment centers to find out how to get a full assessment and diagnosis. The assessment should consider all related physical and psychological problems (other documents in this toolkit explain the diagnostic or assessment process and testing). The four main reasons for doing this are: To obtain as complete a picture as possible about everything that is wrong To develop the best plan for treatment To obtain cost estimates before starting treatment To obtain the benefits the patient is entitled to under his/ her contract for the type of care needed—for example, many insurers provide more coverage benefits for severe mental disorder diagnoses. Some insurers categorize anorexia and bulimia nervosa as severe disorders that qualify for extensive inpatient and outpatient benefits, while others may not. Page | 70