QUESTION: Can our health 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 has 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 plan is subject to the Mental Health Parity and Addiction Equity Act (see our Checkpoint article), 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 could not require a participant to go through an approval process for anorexia treatment in an inpatient treatment facility that is stricter than what would be required for inpatient treatment of medical/surgical procedures. And, a plan that covers inpatient, out-of-network treatment outside of a hospital for medical/surgical conditions if the prescribing physician obtains preauthorization generally could not 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 particular disabilities. And the EEOC 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, advice of experienced legal counsel should be sought before implementing plan provisions limiting these types of benefits.
For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.A (“What Is Mental Health Parity and Who Must Comply?”), IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”), and XX.E (“Exclusions and Limitations That Raise Potential ADA Issues”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C.2 (“MHPA and MHPAEA: Mental Health Parity”).
Contributing Authors: EBIA Staff.