Eating disorder insurance coverage often inadequate

Jennifer Nelson

Eating disorders affect people from all walks of life, most frequently young men and women, teens and children. As many as 10 million females and 1 million males in the U.S. battle anorexia or bulimia, according to the National Eating Disorder Association. Anorexia has the highest mortality rate of any mental illness. And as many as 13 million more struggle with binge eating or a dieting obsession.

Eating disorder insurance coverage often inadequate
Eating disorder insurance coverage often inadequate

Despite these statistics, health insurance in most states doesn’t provide adequate treatment for people affected by eating disorders. Mental illnesses that are “biologically based,” such as brain diseases like schizophrenia and obsessive-compulsive disorder (OCD), are covered. However, eating disorders are not considered biological by insurers and fall outside their coverage.

“Anyone who thinks eating disorders are lifestyle choices needs to get into this century,” says Lynn Grefe, president and CEO of the National Eating Disorder Association.

The National Institute of Mental Health has declared that eating disorders are biologically based illnesses, Grefe says. In fact, because of their mental and physical components, eating disorders are among the most complex illnesses in the spectrum of mental disorders.

Patients often need immediate hospitalization, but their insurance may cover only physical treatment and not address mental issues. “That’s like a drive-through treatment at McDonald’s,” Grefe says. “Put a feeding tube in them, restore their weight, and then send them home. It doesn’t work.”

What’s behind lack of coverage?

According to eating disorder experts, one of the problems is that the standard of care at treatment centers across the country differs. Some patients need residential treatment, some need outpatient therapy — it’s different in every case. The eating disorder community is striving to educate the public that a one-size-fits-all approach doesn’t apply to eating disorder treatment.

When insurance companies do cover treatment, they base “wellness” on the person’s body mass index (BMI), not on the psychiatric care needed after the patient reaches the required BMI . Insurers also place limitations on care — 30 days at a residential treatment center or 25 lifetime outpatient therapy sessions. This is different from serious illnesses like cancer, where insurers don’t insist that patients are cured within a set time period.

Federal lawmakers have tried to tackle the problem. The Wellstone-Domenici Mental Health Parity Act of 2010 ensured that employers with 50 or more employees, and whose group health coverage included mental illness coverage, had to include coverage for treatment of eating disorders.

However, eating disorder experts say the federal law doesn’t do enough, critics say, as it lacks specifics about coverage limits, covered treatments and covered drugs. “States and insurance companies continue to balk at treating mental illnesses, including eating disorders. And unfortunately, many people have died as a result,” says Kathleen MacDonald, education coordinator of the F.R.E.E.D. Foundation, a nonprofit advocacy group that battles eating disorders.

This year’s passage of the Affordable Care Act gives some hope to sufferers and their families. Under the reform law, some provisions will improve care for eating disorders by allowing young adults to remain on their parents’ insurance until age 26, forbidding insurers to deny eating disorder coverage because it is a preexisting condition, and removing lifetime caps on mental health benefits.

However, advocates say there’s still room for insurers to deny treatments based on what they consider “medically necessary,” and states still can determine the benefits their state-licensed insurers must provide.

Insurance limitations

Insurers can refuse coverage if a patient’s body mass index (BMI) is not low enough. The Federal Substance Abuse and Mental Health Administration determined that a BMI of 17.5 is a “strict indicator” of anorexia, and yet Anthem Blue Cross requires someone to have a BMI of less than 15 to qualify for inpatient care.

“I know people who get turned down for treatment and have to go home and lose more weight,” Grefe says.

With Blue Cross Blue Shield, patients can elect for a higher monthly premium for a policy that provides more coverage, but 30 days of inpatient care is the maximum. Other providers allow a set amount of outpatient therapy sessions, but usually it’s limited to 10 to 20 visits.

The law

Lisa Kantor, a California attorney who represents clients who have been denied benefits for eating disorder treatment and other mental health disorders, sued Blue Cross and Blue Shield of California and won in 2011, holding the California’s Mental Health Parity Act must provide coverage of all “medically necessary treatment” for nine severe mental illnesses, including eating disorders, under the same financial terms applied to physical illnesses.

“The decision was the first of its kind in the country, paving the way for other mental health parity rulings,” Kantor says.

State-by-state parity mandates (laws that say mental illnesses must be covered the same way physical illness is), may be the key to forcing insurers to cover eating disorders adequately. Forty-eight states have some form of parity laws, which force insurers to cover mental health disorders the same way they cover physical disorders. But only 25 states have laws that include eating disorders, and these laws don’t affect all insurance plans.

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