Health Insurance and the Conflict with Eating Disorders
Insurance can be difficult to deal with when it comes to overall health care. However, it is extremely lacking when it comes to insurance coverage for those battling an eating
What Criteria is Required for Eating Disorder Insurance Coverage?
The insurance criteria required for an eating disorder diagnosis is based on the most common symptom and presentations of these disorders. These criteria can be found in the Diagnostic and Statistical Manual (DSM) of Mental Illness.
However, eating disorders are complex and not all individuals exhibit all the symptoms or fulfill all criteria all the time. While there are a lot of symptoms and signs associated with eating disorders, insurance coverage criteria is often solely based on weight or physical aspects. More specifically, the coverage criteria focuses on weight ranges “below average”.
Who Does Eating Disorder Insurance Criteria Affect?
Anyone with an eating disorder is affected by insurance criteria. Just based on the typical descriptions of the different types of eating disorders, we can already see how focusing on “below weight ranges” can negatively affect health insurance coverage.
Anorexia Nervosa – characterized by low weight
Bulimia Nervosa – characterized by average or above-average weights
Binge Eating Disorder – characterized by average or above-average weights
This also highly affects those that are considered Atypical. Atypical Anorexia is when an individual “meets all of the criteria for anorexia nervosa…except that despite significant weight loss, the individual’s weight is within or above the normal range.”
Any individual can be of “normal” weight and still deep within their eating disorder. This proves that basing criteria solely on weight does not accurately or adequately reflect the “medical necessity” that is required for health insurance coverage.
What are the Issues with Health Insurance and Eating Disorders?
Sadly, there are many issues with health insurance for those with eating disorders such as criteria, coverage, and denial of coverage:
Criteria:
Basing insurance criteria solely on weight fails to factor in the psychological aspect which is a huge part of eating disorders. While it is essential for weight restoration to take place, full recovery requires psychological growth as well.
Not only is insurance only factoring weight in its “medical necessity” criteria, some insurances will drop medical coverage after “partial weight restoration”. Individuals considered “not underweight” or “partially restored” are at risk of having insurance coverage jeopardized due to no longer meeting criteria and have limited access to treatment. This often leaves individuals feeling that they are not sick enough to receive treatment. This increases chances of relapse and feeds into poor mental health, further delaying recovery.
Coverage:
Initial insurance criteria can be difficult to establish and limit overall coverage that mental health patients receive. It can be difficult to prove that a patient has “medical necessity” for treatment if they are not below a normal weight range.
Insurance evaluations are also often completed by a physician provided by the insurance company. That means that the doctor evaluating a patients “medical necessity” is one that has not established care for the patient or acquired a history of care through a doctor-patient relationship.
Denial:
There several cases in which individuals seeking medical treatment for an eating disorder can be denied insurance coverage. Even if a patient has successfully met the “medical necessity” and is ready to enter a treatment facility or program, they can be denied or delayed due to lack of space. Many networks have a limited number of mental health professionals which can limit the number of patients that can receive care at a location.
Patients can also be denied or cut off from insurance coverage due to patient history. Typically, individuals need to fail lower levels of treatment to deem “medical necessity” for insurance to approve coverage for higher levels of treatment. However, individuals may be denied or cut off from coverage if past treatments at the same level of care have been “ineffective” at achieving full recovery or if the patient has had a “lack of progress”
Insurance coverage lies in a huge gray area. A client can be denied coverage if the patient fails to restore weight or continues eating disorder behaviors, but also denied or cut off once weight is restored, partially restored, or behaviors stop due to no longer meeting “medical necessity”.
Cutting off coverage of treatment can negatively impact patients, especially those with depression or suicidal ideation in relation to body image. Patients who are restoring body weight go through the refeeding process which involves many physical changes beyond weight gain. It can include acne, bloating, constipation, nausea, among many others. These changes can contribute to depression or suicidal ideation making the battle to recovery extremely challenging.
It can be detrimental, and potentially fatal, to cut off a patient who has restored weight before they have had enough psychological treatment. This sets the patient up for relapse or further difficulties and prolongs the delay to recovery.
How Expensive is Eating Disorder Treatment?
Eating disorders are some of the most expensive mental illnesses to recover from. This is simply due to the fact that eating disorders are complex and affect physical health, mental health, typically require medication, therapy, nutritional consulting, and sometimes even family therapy. It can also involve a lengthy treatment and recovery process.
Insurance doesn’t always cover the treatment team members required for recovery, not to mention the costs of treatment in any facility or program. Unfortunately, this means that many patients who need treatment are unable to afford it or unable to stay in a program. For those that are lucky enough to obtain insurance coverage, it doesn’t always cover the full treatment and they are often left with a hefty bill.
For a patient in residential treatment, the average stay can range anywhere from 50-80 days. This does not factor in any early discharges due to insurance cuts or that fact that some patients may need more than one stay in a residential treatment on their journey to recovery.
A report by NEDA revealed that “when covered by insurance, patients and/or their families may still be forced to pay the following after meeting their deductible: 0-40% for inpatient treatment, 20-50% for tube feeding and surrounding services, and 20-50% for residential treatment. This can result in a fully insured patient having to pay $50,000 for a single admission in residential treatment.”
“The CEO of one IOP quoted that at nine hours per week, six weeks of treatment costs between $7,000 and $10,000. At this same program, PHP costs between $17,000 and $20,000 per month. Residential programs cost roughly $30,000 per month, which can amount to over $100,000 for a longer stay. Inpatient treatment is also very expensive. A study examining costs of an inpatient-partial hospitalization program for anorexia patients found average cost per day to be $2295 for inpatient and $1567 for outpatient treatment.”
How Can the Disconnect Between Eating Disorders and Insurance be Fixed?
There is no simple fix for the disconnect between health insurance and eating disorders. For now, the best thing to do is to raise awareness to these issues and emphasize that change is needed.
If insurance allowed coverage for earlier care, many individuals would be able to reach recovery sooner and before they exhibited severe symptoms or conditions. Allowing for earlier care, for proper lengths of time from the beginning, could potentially reduce the amount of care needed overall. And even potentially reduce or prevent relapses. Ultimately this could reduce health care cost in the long term.
We can work together to raise awareness. Donations to non-profit organizations like NEDA, the National Eating Disorder Association, can help raise funds for supportive services, research, and overall promote change. In the meantime, remember that I love you, and should love you too, and if you are struggling with an eating disorder, you are sick enough.
If you or someone you know is struggling, head to the Resources page for help or further education.
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