Medicare Eating Disorder Coverage

Struggling with an eating disorder can be an enormous mental, physical, and emotional challenge. That’s why it’s especially unfortunate that finances add another stressor for so many people looking for treatment.

With some residential treatment programs costing upwards of $30,000 per month, cost is a major barrier to care for many. [1]

Fortunately, some health insurance policies, including Medicare, can help you cover the cost of these programs, through insurance coverage.

Does Medicare Cover Eating Disorder Treatment?

In a word: Yes, Medicare insurance benefits do cover eating disorder treatment programs, though the types of care and treatment options available for coverage will depend on the details of your condition, your medical history, and your insurance plan.

There are a number of eating disorder treatment centers throughout the country that accept Medicare insurance. But in order for your Medicare insurance coverage to kick in, you will need to meet certain conditions.

In a vast majority of cases, you will be required to try an outpatient treatment program before you’ll be accepted for coverage for more intensive—and costly—levels of care.

It’s also important to note that the amount of inpatient coverage you receive will change throughout the duration of your treatment. Typically, the longer you stay in a program, the higher the copayment will be. [2]

What Will Medicare Cover?

While Medicare may draw some lines on when it starts offering eating disorder recovery support, the insurance company does extend coverage for a number of different eating disorders.

According to the Centers for Medicare and Medicaid Services, the following eating disorders are recognized and covered by Medicare: [3]

Aside from extending coverage for these specific conditions, Medicare coverage can also be extended in a number of other situations.

Mental health

Medicare Parts Coverage and Mental Health Services

Eating disorder treatments and therapies are considered mental health treatment, and are covered under Medicare’s mental health coverage.

Medicare has four parts, A, B, C, and D, and each part covers different aspects of care for patients seeking treatment for mental health conditions, including eating disorders.

Medicare Part A

Medicare Part A, or hospital insurance, covers inpatient treatment. These are usually provided in a hospital setting. Some aspects of this treatment your plan will cover include your room, meals, medical supplies, nursing care, and required therapies. [2]

Please note that for each benefit period, you will be required to pay a deductible. You will also be required to make a daily coinsurance payment, from day 61 on. (The first 60 days of inpatient treatment are typically covered completely.) [2]

If you stay in the hospital for more than 90 days, you will be required to pay an additional coinsurance fee per each “lifetime reserve day” you use. Each individual has a maximum of 60 reserve days over their lifetime. Once you exceed these days, your Medicare coverage will be exhausted, and you’ll have to start covering all costs out-of-pocket. [2]

Medicare Part B

Medicare Part B covers outpatient treatment options. These types of services are typically provided outside of an eating recovery center or hospital, and may be prescribed individually. For instance, nutritional counseling, visits with a psychiatrist, and laboratory tests are typically ordered by your physician.

Medicare Part B may also cover partial hospitalization if your doctor certifies that you require inpatient treatment. [2]

When using Medicare Part B, you will be required to pay a percentage of the Medicare-Approved Amount for all services you receive from a physician or qualified mental health professional. After meeting the Part B deductible, you will also be required to pay coinsurance for every day of partial hospitalization. [4]

Medicare Part D

This section covers prescription drugs which may be prescribed to help you treat an eating disorder or other related mental health condition. There are several Part D plans, each with its formulary or list of covered drugs. [5]

Check the details of your plan and your membership materials or contact a Medicare representative plan for details on how to access eating disorder treatment and other mental health benefits.

Levels of Eating Disorder Treatment

Medicare covers all levels of eating disorder treatment. [6] This includes outpatient, inpatient, partial hospitalization, and intensive outpatient treatments.

However, to receive coverage for your required therapy, a physician has to prove that it’s medically reasonable and necessary.

Types of Treatment Covered

Medicare covers many different kinds of eating disorder treatments and mental health services, including therapy programs and medication. Your chances of coverage approval are higher, however, if the treatment is evidence-based.

Some general types of care Medicare is likely to cover include:

  • Psychotherapy, including individual or group therapy
  • Nutritional counseling and therapy
  • Medical monitoring, such as meetings with nutritionists and mental health professionals
  • Medication approved to treat eating disorders or related mental health conditions
  • Annual wellness visits
  • Advance care planning, in which a Medicare representative will help you plan treatment
  • Family therapy

Different Medicare plans will cover different portions of your treatment, for different—and, often, limited—periods of time.

It’s also important to seek prior authorization before entering a program, and to remember that Medicare also requires a continuing review of costs and interventions.

What Does Medicare Not Cover?

While Medicare offers a number of treatment coverage options, the plan only covers services that are considered medically necessary.

Things that the insurance provider generally does not consider medically necessary include: [2]

  • Private duty nursing
  • Having a television or phone in your hospital room
  • Personal items, including razors, socks, and toothpaste
  • A private room, unless a doctor proves that it’s medically necessary
  • Report preparation
  • Results and data interpretation or explanation
  • Transportation
  • Outpatient meals
  • Phone service apps

Medicare also does not cover recreational or diversionary therapy. [7]

Transportation

How to Start the Treatment Process Using Medicare

The best approach to starting your eating disorder treatment process using a Medicare traditional plan is to obtain prior authorization. This means getting Medicare’s approval for coverage before starting treatment. [8]

If you are getting your services through an Advantage Plan, you first need to call your provider and ask to be assigned a case manager. The case manager is a representative who will explain to you all the facilities available for your treatment. They will also help you identify hospitals and treatment centers that accept Medicare.

Treatment Centers That Accept Medicare

Finding which programs accept Medicare can be tricky. There are several methods that can help you figure this out, especially if you’re seeking out prior authorization. You can:

  • Contact a Medicare representative, to ask about nearby programs in their network
  • Contact Medicare and asked to be assigned a case manager, who should assist you in finding a covered program
  • Do your own research, find a program you like, and call them directly and ask if they accept Medicare

Navigating the complex maze of health insurance can be an additional complication while trying to make major changes to the way you think, feel, and behave. It’s an unfortunate reality in our modern medical world, but once you’re able to secure coverage or assistance, it can open up the door to recovery, and help bring on a brighter, happier, and healthier future.

Resources

  1. Navigating Insurance Coverage for Eating Disorder Treatment. Centers for Discovery. Accessed February 2023.
  2. Mental health care (inpatient). Medicare.gov. Accessed February 2023.
  3. ICD-10-CM/PCS MS-DRG v39.1 Definitions Manual. Centers for Medicare & Medicaid Services. Accessed February 2023.
  4. Mental health care (outpatient). Medicare.gov. Accessed February 2023.
  5. Drug coverage (Part D). Medicare.gov. Accessed February 2023.
  6. Does Medicare Cover Eating Disorder Treatment?. Medicare Plan Tips. Accessed February 2023.
  7. Medicare Mental Health Booklet. Centers for Medicare & Medicaid Services. Accessed February 2023.
  8. Medicare Prior Authorization. Center for Medicare Advocacy. Accessed February 2023.

Published on May 19, 2023 Published on EatingDisorderHope.com