Health Insurance 101 — Key Highlights

1. Purpose & Overview

• This resource helps you understand essential health insurance topics—the terminology, levels of care, in-network vs. out-of-network rules, policy review, and how to advocate for the care you deserve.

2. Glossary & FAQs

• A downloadable insurance glossary and FAQ section aim to demystify complex terms and questions, especially for those navigating eating disorder treatment.
  
  

3. Does Insurance Cover Eating Disorder Treatment?

• Many plans do, but coverage varies. Services often include therapy (individual, group, family), medical monitoring, nutritional counseling, PHP (Partial Hospitalization), and IOP (Intensive Outpatient Program). Some plans, however, impose limits on duration and types of services. 

4. Common Reasons for Denial of Coverage

• Denials may occur due to:
  
  

  • Lack of Medical Necessity
    
    

  • Lack of Coverage for certain levels (e.g., residential care)
    
    

  • Step Therapy Requirements (must try lower level first)
    
    

  • Geographical Restrictions
    
    

  • Policy Limitations (e.g., treatment not listed in Explanation of Benefits).
    
    

5. Plan Types Explained

• HMO (Health Maintenance Organization): In-network only, PCP required.
  
  

• EPO (Exclusive Provider Organization): In-network only except emergencies.
  
  

• POS (Point of Service): Lower cost for in-network; out-of-network benefits at higher cost; PCP referrals required.
  
  

• PPO (Preferred Provider Organization): Flexible, no referral needed for out-of-network, but higher out-of-pocket costs.
  
  

6. Metal Levels of Coverage (Marketplace Plans)

• Bronze: Insurance pays ~60% (higher out-of-pocket costs, lower premiums)
  
  

• Silver: ~70% coverage
  
  

• Gold: ~80%
  
  

• Platinum: ~90% coverage (lowest out-of-pocket, highest premiums).
  
  

7. In-Network vs. Out-of-Network Providers

• Finding In-Network Providers: Use your insurer’s website or Member Services, or ask your provider directly.
  
  

• No In-Network Providers? You might negotiate a Single Case Agreement (SCA)—allowing in-network rates for an out-of-network provider.
  
  

• Using Out-of-Network Providers: Some plans offer out-of-network benefits, often with reduced reimbursement and higher costs. Options include sliding-scale fees or negotiating an SCA.
  
  

8. Insurance Authorization & Appeals

• Certain treatments require pre-authorization.
  
  

• If denied coverage, you have the right to appeal—and many denials are overturned. Your provider can help, and you may also need a legal advocate or patient advocate.
  
  

9. Coverage Across State Lines

• Some plans cover treatment in other states, but verify your in-network list before starting care.
  
  

10. Who to Contact

• Member Services (info on your card) handles coverage questions. Some plans separate medical and behavioral health lines.
  
  

• Ask for your benefits summary via your insurer’s site or your HR department.
  
  

11. Pre-Existing Conditions & ACA Protections

• Under the Affordable Care Act (ACA), insurers cannot deny coverage or charge more based on pre-existing conditions, including eating disorders.
  
  

• Exceptions include short-term or grandfathered plans (pre-March 23, 2010), which may still exclude such conditions. If denied, seek legal or patient advocacy support.

12. Questions to Ask Your Insurer

Coverage Questions:

• Is mental health covered?
  
  

• Are outpatient/higher levels of care (IOP, PHP, residential) covered?
  
  

• Is Medical Nutrition Therapy (MNT) covered?
  
  

• Are there limits on visits or services?
  
  

Cost & Payment:

• What are my copays, deductible, out-of-pocket maximum?
  
  

• Do I have out-of-network benefits?
  
  

Eating Disorder–Specific:

• Any limitations/exclusions?
  
  

• Can I access or receive a copy of coverage guidelines?
  
  

13. Rights & Advocacy

• Commercial plans may offer some mental health coverage; government plans like Medicaid/Medicare are often less comprehensive for eating disorders.
  
  

• Downloadable self-advocacy toolkits are available to help navigate and challenge gaps in coverage.
  
  

For more information, go to  Project HEAL's website.