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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. Page | 68