TIPS ON ADVOCATING
FOR COVERAGE
SPECIAL CONSIDERATIONS FOR EATING DISORDER PATIENTS
LISA S. KANTOR, ESQ.
KANTOR & KANTOR
(800) 446-7529
WWW.KANTORLAW.NET
LKANTOR@KANTORLAW.NET
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number One:
• Familiarize yourself with your insurance policy or
health benefit plan.
• Obtain a copy from your employer or insurance
company if you don’t have one.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number Two:
• Find out if State or Federal Mental Health
Parity Applies to your policy.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
THE FEDERAL MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
•
Signed into law on October 3, 2008; applies to plan years beginning on October 3, 2009
•
Applies to all groups, private and public, over 50 employees, self-funded and insured
•
Does not apply to individual policies or small groups
•
Does not require coverage of mental health
•
Allows the insurer to define “mental health”
•
Applies to six classifications of benefits: inpatient, in- network; inpatient, out-of-network;
outpatient, in-network; outpatient, out-of-network; emergency care; prescription drugs
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
THE FEDERAL MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
•
Treatment limitations (e.g. frequency of treatment, number of visits, number of days,
or similar limits on scope or duration of treatment) imposed on mental health
benefits may NOT be more restrictive than those imposed on medical/surgical
benefits
•
There can be NO separate cost-sharing requirements or treatment limitations that
are applicable only to mental health
•
Plans are prohibited from using “separate but equal” deductibles. This means that
mental health and medical/surgical benefits must add up together towards the
same, combined deductible
•
Federal parity law is the floor or minimum
•
State laws that require more or better coverage are not preempted
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
STATE PARITY LAWS
•
•
•
Come in a variety of forms
Do not apply to self-funded plans
Must analyze to understand scope of protection:
1.
What is the definition of mental illness?
2.
When are insurers required to provide
medically necessary mental health
coverage?
3.
What is the parity mandate? What has
to be equal or equivalent?
4.
What are the exceptions?
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number Three:
• Understand the insurance policy’s coverage
for treatment at an in-network facility versus
an out-of-network facility.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number Four:
• Ask your insurance company for a list of innetwork treatment facilities.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number Five:
•
If the insurance company has no in-network
facilities in your area or state, or no in-network
facilities appropriate to treat you, ask your
insurance company for a single case agreement
with your preferred treatment facility.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
•
Document that the
treatment is
medically
necessary by
providing written
support from your
providers, coworkers, friends,
and/or a personal
statement.
•
Document what
forms of therapy
and treatment you
have tried by
submitting copies
of all treatment
records to the
insurance
company.
WWW.KANTORLAW.NET
SPECIAL CONSIDERATIONS FOR EATING
DISORDER PATIENTS…
Number Six:
•
Make sure that you, and your facility, and all of your
doctors, communicate with the insurance company in
writing and retain records of all correspondence.
WWW.KANTORLAW.NET
TIPS ON ADVOCATING
FOR COVERAGE
SPECIAL CONSIDERATIONS FOR EATING DISORDER PATIENTS
LISA S. KANTOR, ESQ.
KANTOR & KANTOR
(800) 446-7529
WWW.KANTORLAW.NET
LKANTOR@KANTORLAW.NET
WWW.KANTORLAW.NET