Wednesday, April 3, 2013

Is Parity Failing You?

Have you been denied coverage for your eating disorders treatment in the last five years that may be a violation of the parity law?  If so, then we need to hear from you.  The Mental Health Parity and Addiction Equity Act of 2008 requires insurance companies to ensure that co-pays, deductibles and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the requirements or limitations applied to medical/surgical benefits. Yet we often hear from people that were denied equal coverage by their insurance companies. Now we need to hear from you.

Have you experienced any of these common problems?

1.  Insurance companies deny treatment as they do not consider the care as "medically necessary".  They use their own definition of medical necessity, versus the standard of care and best practices in the treating community.

2. Provider reimbursement rates are too low, so the provider has to offer services out-of-network and the patient has to pay a higher out of pocket for their treatment.

3. The insurance company has labeled my treatments as “experimental” or "experiential" and therefore are refusing to pay for those treatments, leaving the patient to pay 100% out of pocket, or go without.

4. The insurance company says that my plan does not cover residential treatment or intensive outpatient care.

5. The insurance company says that my plan does not cover inpatient or residential treatment unless it is provided in an acute care hospital, but most of the treatment providers are non-hospital based facilities (e.g. a residential care facility specific for eating disorders treatment).

6. The insurance company says that they do not authorize any inpatient treatment at all for my anorexia, bulimia or other eating disorder, and that I must be treated only on an outpatient basis.  

7. I have requested from my insurance company the reason why they have denied my care and they will either not respond to my requests for further information, or they refuse to tell me what they do for medical and surgical care, or they refer me to a website that I cannot discern any information from.

8. Outpatient sessions are being limited by utilization review (also known as medical necessity review) and this is not being done for medical and surgical conditions.

9.  Insurance companies deny patients treatment (or tell them up front that their treatment isn't a covered benefit) because eating disorders are not a biologically based or serious mental illness (BBMI and SMI).

10.  Insurance companies deny people treatment because it is considered "educational services".

11. Any other reason you were denied treatment for your eating disorder in a way that is more restrictive than medical/surgical coverage (e.g. visit limits).

What You Can Do?
If you were denied coverage for any of the 11 reasons listed above. Please let us know right away by emailing Melanie Morris at If you have your denial letter please attach it. We’ll help you use it to let Congress and the Administration know that Parity for eating disorders coverage must be enforced and that any regulations should explicitly state this.

What is Next?
After a law passes, the Administration promulgates regulations (just a fancy way of saying interprets the law and gives some guidance on how it should be interpreted by the insurance companies). However the Administration has yet to put out the final regulations on Parity—it has been four years!!! We need to ensure that when these regulations come out they give strong guidance to the insurance companies on how eating disorders should be covered at parity.

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