Does Medi-Cal Cover Treatment for Eating Disorders?

Eating disorder cases are prevalent in California, with an estimated 9% of the state’s population experiencing one of these conditions over the course of their lifetime. [1] Still, many treatment programs can be quite expensive, and the cost presents a barrier of entry for many patients who seek care.

Fortunately, there are several health insurance policies that help cover the cost of eating disorder treatment for their members. In California, one of the most popular of these plans is the government-funded health insurance program, Medi-Cal.

If you or a loved one is struggling with an eating disorder, and use Medi-Cal health insurance, you may have some questions about what your policy will or will not cover.

Does Medi-Cal Cover Eating Disorders Treatment?

Yes. Medi-Cal started providing free health insurance policy coverage for all residents over the age of 50, regardless of immigration status, starting from the first of May 2022. This includes coverage for the treatment of eating disorders. [5]

Treatment can be accessed through Medi-Cal’s managed care health plans (MCPs). These plans work to coordinate and provide eating disorder treatment deemed medically necessary for members who are officially diagnosed with one of these conditions. [2]

Individuals experiencing eating disorders may also receive Specialty Mental Health Services from a county Mental Health Plan. Medi-Cal Specialty Mental Health Services (SMHS) constitute a range of services provided by county Mental Health Plans and several agencies that contract with them. [3]

Insurance

How Does Medi-Cal Eating Disorder Treatment Work?

Medi-Cal’s obligations to cover eating disorder care vary, depending on the age of the patient.

The plan must cover any treatment for eating disorder symptoms for members under 21 years old, so long as the program is determined medically necessary by a physician. Coverage comes through Medi-Cal’s managed care plans and mental health plans. [2]

Beneficiaries 21 and older are required to demonstrate the necessity of specialty mental health services. This can be done by explaining: [4]

  • How their condition causes significant disruption to their daily life.
    or
  • How their condition contributes to a deteriorating quality of life.

Additionally, beneficiaries over the age of 21 are required to show that the treatments and therapies they require will both: [4]

  • Address their eating disorder(s)
    and
  • Diminish the impairments they cause

In some instances, they may also be required to show that the eating disorder cannot be corrected by physical intervention alone. [4]

MCPs vs SMHS

Eating disorders are complex conditions that may affect an individual’s mental and physical health, and a proper treatment plan can include everything from individual therapy and family therapy to meal planning and nutritional assessment.

As such, part of the treatment of conditions like anorexia nervosa and bulimia nervosa will be covered by both mental health plans and MCPs.

Generally, managed care plans are geared more toward primary and preventative care, while SMHS plans focus more specifically on mental health conditions.

A Medi-Cal representative should be able to help you better understand the relationship between these two plans.

What Will Medi-Cal Cover?

Medi-Cal mental health plans cover any psychiatric treatment considered medically necessary, including both inpatient programs and outpatient programs. For Medi-Cal beneficiaries over the age of 21, a service is considered “medically necessary” when it’s reasonable and necessary for the protection of life, prevention of illness or significant disability, or the alleviation of severe pain. [3]

MCPs tend to focus more on physical complications, providing coverage for care considered necessary to address a member’s physical health conditions. This includes paying for and arranging treatment for patients requiring hospitalization as a result of eating disorder complications, even if they don’t meet the criteria for psychiatric inpatient treatment.

Some of the different types of tests, treatments, and therapies that are regularly covered by these plans include: [2, 3, 6, 7]

  • Screening examinations to determine the presence of eating disorders.
  • Medically necessary treatments for stabilizing patients with eating disorders.
  • Facility charges claimed by emergency departments.
  • Residential eating disorder programs.
  • Partial hospitalization programs
  • Medically necessary physical health treatments ordered by a physician
  • Individual or group counseling
  • Outpatient specialty mental health services
  • Lab work, drugs, and supplies
  • Inpatient mental health services
  • Residential treatment services

Outpatient Treatment Services Covered by Medi-Cal

Beneficiaries diagnosed with eating disorders are eligible for outpatient treatment, including specialty mental health services.

Some covered outpatient treatments include: [6,7]

  • Psychological testing to evaluate a mental health condition
  • Nutritional counseling
  • Individual or group therapy
  • Some medication consultations

Inpatient Treatment Programs Covered by Medi-Cal

Medi-Cal mental health plans cover inpatient specialty mental health services for members diagnosed with feeding and eating disorders.

However, it’s important to note that mental health plans only cover the cost of inpatient care at hospitals and treatment centers that participate in fee-for-service (FFS) programs with Medi-Cal. [4]

Partial Hospitalization Programs Covered by Medi-Cal

Medi-Cal covers the cost of partial hospitalization programs for eating disorder patients.

MHPs and MCPs share a joint responsibility to ensure that patients gain access to all necessary services required for the treatment of eating disorders. Medically necessary specialty mental health services are covered by mental health plans, while the physical health component is addressed by managed care health plans. [2]

To ensure you don’t have problems with eating disorder treatment coverage, you should give your county updated information each time you change your address or phone.

What Happens When You Travel Out of California?

Since Medi-Cal is run by and for the state of California, it’s common to wonder whether treatment at an out-of-state facility will be covered.

If you travel out of state, it’s important to always carry your Medi-Cal card. Your Medi-Cal health care plan may still be able to help in times of emergency due to severe illness. [8]

For anything that’s not an emergency, you will need approval from your managed care plan before your treatment coverage will be approved. That generally means paying out-of-pocket for any providers who do not accept Medicaid.

What Does Medi-Cal Not Cover?

Medi-Cal will not cover treatments that are deemed medically unnecessary. For instance, a high risk of relapse without constant supervision will not be considered a condition in need of medically necessary treatment.

Provider

How to Start the Treatment Process Using Medi-Cal

The best way to start your treatment process using Medi-Cal is to contact the Medi-Cal Managed Care Office of the Ombudsman. This office will help you: [8]

  • Gain access to Medi-Cal specialty mental health services
  • Get information about participating treatment centers, in-network providers, and referrals
  • Navigate the MCP and specialty mental health system for the treatment of eating disorders.

The office also investigates member complaints concerning managed care plans and county mental health plans. This means if you are not satisfied with your application response, you can get clarity or appeal through the office of the Ombudsman. [8]

Treatment Centers Accepting Medi-Cal

There are several treatment centers that accept Medi-Cal.

If you are getting your coverage through a managed plan, you may have a care manager who can give you information about in-network providers. Otherwise, you can contact Medi-Cal to ask for more information, or inquire directly with a program whether they accept your plan.

Navigating the healthcare system while trying to simultaneously manage an eating disorder can be stressful, difficult, and frustrating. But Medi-Cal has a number of ways to provide the help you need to get on the road to recovery.

Resources

  1. Social & Economic Cost of Eating Disorders in California. The Strategic Training Initiative for the Prevention of Eating Disorders. Accessed January 2023.
  2. Medi-Cal Managed Care Health Plan Responsibility to Provide Services to Members with Eating Disorders. (2022, March 17). State of California Department of Health Care Services. Accessed January 2023.
  3. Medi-Cal Specialty Mental Health Services Covered by County Mental Health Plans – Adults Ages 21 and Older. (2022, September 1). Disability Rights California. Accessed January 2023.
  4. An Advocate’s Guide to Medi-Cal Services. (2020). National Health Law Program. Accessed January 2023.
  5. Medi-Cal Program. Health and Human Services Agency. Accessed January 2023.
  6. Mental Health Services. (2023). California Health & Wellness. Accessed January 2023.
  7. Behavioral Health Care. California Department of Managed Health Services. Accessed January 2023.
  8. My Medi-Cal: How to Get the Healthcare You Need. California Department of Health Care Services. Accessed January 2023.

Published on April 29, 2023. Published on EatingDisorderHope.com