Tips on Advocating for Coverage Special Considerations for eating disorder patients

W W W. K A N T O R L AW. N E T

TIPS ON ADVOCATING FOR COVERAGE

SPECIAL CONSIDERATIONS FOR EATING DISORDER PATIENTS

LISA S. KANTOR, ESQ.K A N T O R & K A N T O R( 8 0 0 ) 4 4 6 - 7 5 2 9W W W . K A N T O R L A W . N E TL K A N T O R @ K A N T O R L A W . N E T


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.

Number Two:

• Find out if State or Federal Mental Health Parity Applies to your policy.



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



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



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?





Number Three:

• Understand the insurance policy’s coverage for treatment at an in-network facility versus an out-of-network facility.



Number Four:

• Ask your insurance company for a list of in-network treatment facilities.



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.


• Document that the treatment is medically necessary by providing written support from your providers, co-workers, 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.




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.


TIPS ON ADVOCATING FOR COVERAGE

SPECIAL CONSIDERATIONS FOR EATING DISORDER PATIENTS

LISA S. KANTOR, ESQ.K A N T O R & K A N T O R( 8 0 0 ) 4 4 6 - 7 5 2 9W W W . K A N T O R L A W . N E TL K A N T O R @ K A N T O R L A W . N E T

Date post:	15-Feb-2016
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Tips on Advocating for Coverage Special Considerations for eating disorder patients

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