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Can Our Plan Limit Benefits for Treatment of Eating Disorders?

06.14.2019

Question: Can our health care plan include a provision that restricts benefits for treatment of eating disorders such as anorexia?

Answer: You should think twice before implementing a health plan provision that places special restrictions on benefits for treatment of eating disorders. To begin, coverage for eating disorders must be consistent with the federal mental health parity requirements. Recent legislation and agency guidance have emphasized that eating disorders are mental health conditions and, therefore, treatment of an eating disorder is a mental health benefit.

This means that, if your health care plan is subject to the Mental Health Parity and Addiction Equity Act, it must provide parity between medical/surgical benefits and eating disorder benefits as to:

  • Annual or lifetime limits,
  • Financial requirements, and
  • Quantitative and nonquantitative treatment limitations.

For example, your plan generally couldn’t require a participant to go through an approval process for anorexia treatment in an inpatient treatment facility that’s stricter than what would be required for inpatient treatment of medical/surgical procedures. Also, a plan that covers inpatient, out-of-network treatment outside of a hospital for medical/surgical conditions if the prescribing physician obtains preauthorization generally couldn’t exclude all inpatient treatment outside of a hospital setting (including residential treatment) for an eating disorder.

Furthermore, the Americans with Disabilities Act (ADA) may limit your ability to restrict or exclude benefits for a particular disability. There has been litigation alleging that the ADA prohibits plans from providing disparate benefits for those with certain disabilities. And the U.S. Equal Employment Opportunity Commission has stated that the ADA generally prohibits plans from excluding services for a particular disability or defining mental health benefits in a way that makes distinctions based on disability.

Because the rules are complex and exceptions apply, seek the advice of experienced legal counsel before implementing plan provisions limiting these types of benefits.

Team

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