So you’ve made the brave decision to seek out treatment for your eating disorder. Good for you! I’d like to tell you that this is the beginning of a life-changing recovery journey for you. You can look forward to some more hopeful days along with some hard days (with amazing days, too!), but there may be some obstacles that may get in your way. Unfortunately, these obstacles may sometimes include figuring out how to navigate your insurance plan in order to understand the treatment coverage that you deserve.
This may seem like an uphill battle, but fear not! There are plenty of insurance gurus (myself included) at treatment centers like Walden who support their patients every day to get them the treatment that they need. While it is important to have insurance advocates on your treatment team that understand how to speak with insurance companies, there are things you should know and understand as well.
1. What kind of eating disorders are covered by insurance?
Most insurances have an eating disorders benefit and will typically cover the following Eating Disorder Diagnoses, characterized by “Feeding and Eating Disorders” in the DSM-5:
• Anorexia Nervosa
• Binge-Eating/Purging Type
• Avoidant/Restrictive Intake Disorder
• Binge-Eating Disorder
• Bulimia Nervosa
• Other Specified Feeding or Eating Disorder
• Eating Disorder, Unspecified
2. What is a deductible and how much is it?
At Walden, once a phone intake has been completed, our admissions department will check their benefits at no additional charge to the prospective client. Once benefits have been checked, our intake department will inform the client of any deductibles that they will be responsible for paying out of pocket. The deductible (a specified amount of money that you will be required to pay before an insurance company will begin financial coverage of a claim) varies and is dependent upon your insurance company and your specific plan.
For example, if one’s deductible is $1,000.00 and treatment is billed at $500.00 per day, the patient would be responsible for covering the first two days of treatment on their own. Once the deductible is met, many insurance plans will then begin covering at 100%, while other plans require the member to pay a “co-insurance” where they would be responsible for paying a percentage of the cost of treatment which can range from 10-50%.
3. What level of care will insurance pay for?
This is a difficult question as coverage is variable depending on the insurance providers’ criteria for an admission, what benefits the plan will cover, and what plan the member is enrolled in. In my experience, purely anecdotally, the most common level of care that insurance companies approve coverage for, is outpatient individual therapy.
The highest level of behavioral health care is inpatient, followed by residential care (both 24 hours of care, Partial Hospital Program (PHP) and then Intensive Outpatient Program (IOP).
In order to access the above levels of care three things must occur:
• You have the benefits under you plan for these levels of care
• You must meet “medical necessity” which is determined by a variety of factors including severity of symptoms, treatment history, blood work results, current weight, previous weight(s), height and vital signs. These factors will also help the eating disorder treatment center to best determine an appropriate level of care. Most often an agreement will be met between provider and insurer for the level of care requested.
• You MUST be in-network with the provider as not all plans contract with all programs but some plans will allow you to go out of network if you have out of network benefits which typically has a higher deductible and co-insurance cost associated to it.
4. How long will insurance pay for me to stay in treatment?
Again, this is very dependent upon a variety of situations. Has the patient been improving? Are they declining? What kind of plan do they have? Most plans will state that the prospective member has “unlimited days based upon medical necessity” which speaks to a finite number of days at a level of care that gets approved. Once the client no longer meets level of care, they will typically step down to a lesser level of care; for example, they may be admitted into a residential program and once they stabilize and no longer meet medical/clinical criteria due to their progress, then they are typically referred to a Partial Hospital Program (PHP). Conversely, if they do not improve in residential care and are decompensating, then they can be admitted to a higher level of care like inpatient.
5. What if my insurance company doesn’t have an eating disorder benefit?
Unfortunately, this happens. While we take the majority of insurances, including many Mass Health plans, we do see many deserving people not having benefit coverage for life saving services. There are a few things that we might suggest depending on prospective client’s individual financial and personal circumstances.
• Switch insurance plans – this can often be a fairly simple process and easy fix for those whose current plan may not provide the coverage necessary for eating disorder treatment.
• Look into scholarship programs that many non-profit organizations like Project Heal that partner with treatment centers like Walden to provide funding to those who may otherwise not have gotten the chance to receive life-saving treatment.
• Ask treatment centers about their policy for sliding scale payment—not all companies offer this, but many do as a small reprieve from what can be very high costs of treatment.
Regardless of where you are in your recovery, it is important to understand these insurance nuances so that you are able to advocate to receive the treatment you deserve. You are strong and capable of shaping your future.
As always, if you have any questions, please don’t hesitate to reach out to us or to me personally at email@example.com!
Bob Bordonaro is director at Walden’s Peabody clinic. He is responsible for ensuring effective clinical programming, program staffing, selection and supervision of staff, budgeting and compliance with all organizational and regulatory agency standards. Formerly, Mr. Bordonaro was Timberline Knoll’s professional outreach representative for the Northeast region. In this role, he collaborated with professionals in the mental health and medical field, specializing in eating disorders, substance abuse, mood disorders, trauma and co-occurring disorders. Prior to that, Mr. Bordonaro was director of admissions at Laurel Hill and was responsible for managing all aspects of the admissions department. Before working for Laurel Hill, Mr. Bordonaro was Walden’s director of the partial hospitalization program for several years. Mr. Bordonaro earned his master’s in social work from Simmons College. He is the current president of the International Association of Eating Disorders Professionals Metro Boston Chapter and has been a member of the National Association of Social Workers since 1998.