Insurance Coverage for Eating Disorders

A clear and concise understanding of your insurance benefits and what will or won’t be covered for an eating disorder [or a related diagnosis] can be both confusing and overwhelming. As an example, your insurance may list mental health as a covered benefit [ eating disorders fall within that category], but require you to be “pre-certified” for a specific treatment [level of care]. In doing so, the insurance company typically will utilize a set of criteria to determine if the severity of your eating disorder meets their criteria for “medical necessity”. As such, it’s possible you may have the benefit but are denied access to the program or level of care you are looking for.

Typically, when someone considers coming to a residential, day treatment, or intensive outpatient program such as ours, they participate in a clinical assessment to determine their treatment needs. Although most benefits include mental health benefits as well as cover a residential program, a few do not. However, assuming you do have benefits that include the continuum of care [residential, partial hospital, and intensive outpatient options], the provider or program will be better able to estimate what will or will not be approved based on the findings of your clinical interview [assessment]. Often the assessment can be conducted via a structured phone interview.

As if the above isn’t complicated and confusing enough, there is also the matter of what your particular insurance policy requires as a “deductible” and what your “co-pay” would be for particular services. Usually, these will be a function of whether you are requesting services from a “network” or “out of network” provider. Out of network providers [facilities and providers] usually involve a somewhat greater “out of pocket” expense on your part. That said, the good news is that after you reach [spend] a specified amount of your own money, your insurance will typically cover 100% of the remaining costs provided you are “certified” for the treatment you’re requesting.

By way of example, someone coming to a program or provider contracted with XYZ insurance, may have a $250 deductible and no co-pay for residential treatment for an eating disorder . In this instance, the maximum out of pocket expense or financial responsibility is limited to $250 – assuming the insurance company’s medical criteria for that level of care is met. Likewise, someone who has a different plan may have no deductible and no co-pay, and hence have no out of pocket expense. Lastly, someone who is using an out of network benefit will likely still be covered after their deductible is met and, in some instances, have a small daily co-pay during their stay.

Given all the above variables and possibilities, it comes down to finding someone who can verify your benefits and be able to give you a clear understanding of what to expect. In doing so, it is important to realize some of the answers to your concerns can only be estimated and predicted on past experiences with your insurance company. This is because your insurance company will not usually commit in advance to a specific length of stay at a given setting or level of care. As such, you will want to know what contingency plan exists should your insurance company [or the managed care company] decide you no longer need treatment at that level of care or program. In effect, you want to discuss your “worst case scenario” before you commit to a treatment program as well as what the most likely scenario will be. Unfortunately, there is typically some uncertainty when dealing with insurance coverage and treatment. You job is to minimize this uncertainty so you can focus on the task of recovery. Here is where the experience and integrity of the person reviewing your insurance is so important.

This process begins with a call to the provider or facility admissions director. Knowing the proper questions to ask is important. Here are a few questions to ask…

- Are you in-network with my insurance company?
- If not, what is my out of network benefit?
- What is my daily co-pay, if any, at your program?
- What is my maximum out of pocket expense at your
facility for the level of care I need?
[residential, partial, or intensive outpatient]
- What can I expect as an out of pocket expense for a
30 day stay or longer
- What is the average length of stay at your program?
- Will I receive a bill for treatment after I leave?
- Will I know prior to my being admitted a
reasonable estimate of my financial responsibility
- Will you let me know beforehand if there is any
change in what my financial liability will be before
I commit to any recommendation to staying longer?

For more information or any questions you have regarding insurances, benefits, and costs associated with getting help with your eating disorder, you’re invited to email me at mlerner@MilestonesProgram.Org or call your insurance carrier.

Marty Lerner, Ph.D.CEO, Milestones In Recovery