Making Your Way Through the Health Insurance Maze, Part 1

One of the major challenges of getting treatment for an eating disorder is obtaining adequate insurance coverage. Many health-care plans provide short-term coverage for outpatient and inpatient treatment of eating disorders, but others offer none.

Dr. Pauline Powers, a Gainesville, FL, expert in eating disorders and past-president of the Academy for Eating Disorders, has several helpful suggestions for when your insurance falls short of the recommended treatment. According to Dr. Powers, the first step is to have a plan (see box), which will make it easier for you to find the treatment you need. Dr. Powers believes that help is available for those who are persistent and resourceful. She adds, “Remember, no hurdle is too high, and help is usually available.”

When your insurance provider doesn’t offer the recommended treatment

If, for example, you have anorexia nervosa of the binge-purge type and residential treatment is recommended for 60 days, your insurance may only cover 10 days. In this case, first try calling your insurance company and ask to obtain your major medical benefits. It is logical to turn to major medical benefits because the semi-starvation that results from anorexia nervosa is a physiological condition and if untreated will likely result in hospitalization on a medical floor in a general hospital, which will ultimately be very expensive. Eating disorders are medical illnesses and it is worthwhile to mention this fact to your insurance company. (Be aware, however, that typically this will not result in any change on their part. But it is worth a try.)

The next step is to contact the personnel department of the company that purchases the insurance. Remember that insurance coverage is called a “benefit,” but in fact it is a part of the compensation to the worker who has the insurance policy. Insurance coverage is not a gift from the employer. Furthermore, the insurance company is supposed to hold the funds paid by the employer on behalf of the employee and to dispense them according to rules set down by the employer. Thus, the employer can decide to “fire” the insurance company (and ultimately the health maintenance organization, or HMO, or preferred provider organization, or PPO).

The important point here is that it is actually your employer (or the employer of the person who has the insurance policy) who has power over what benefits are provided from the HMO or the PPO. Thus, your personnel department can be helpful. Since the employer pays for the insurance benefits (which can include hiring an intermediary HMO), ultimately (although not immediately) the employer can choose to change insurance companies.

When your insurance company and personnel department are not helpful

Although it is tempting, don’t give up at this point; other steps can be taken. First, let your insurance company know that you have decided to call the insurance commissioner and then call him. When you speak with the commissioner, tell him what has been recommended, the steps you have taken to obtain treatment, and the results. Then follow this up with a letter explaining the difficulties. Keep a copy of this letter for your files. If the insurance commissioner is not helpful, the next step is to contact your state senators and congressmen and congresswomen. If they aren’t helpful, contact your governor.

When your legislators and governor are not helpful

Advocacy groups may be an answer when government officials don’t respond. For example, groups such as the Eating Disorders Association (603 Stewart St, Suite 803, Seattle, WA 98101) can help answer questions and provide help through their advocacy group, the Eating Disorders Coalition for Research, Policy, and Action. The national information and referral hotline is 800-931-2237).

To continue onto part 2, click here.

Making Your Way Through the Health Insurance Maze, Part 1