A Chance to Heal 

Academy for Eating Disorders 

Anna Westin Foundation 

Avalon Hills Residential 

 Eating Disorders Program 

Center for Change 

Dads and Daughters 

Davis Y. Ja and Associates 

Eating Disorders Institute/ 

 Minneapolis 

Eating Disorder Referral and 

 Information Center 

Emily Program 

Gail R Schoenbach / 

 F.R.E.E.D. Foundation 

Gürze Books 

HEED / Helping End 

 Eating Disorders 

Kristen Watt Foundation 

Monte Nido Treatment Center 

National Eating 

 Disorders Association 

Pennsylvania Educational 

 Network for Eating Disorders 

Puenta De Vida 

Renfrew Center Foundation 

Remuda Ranch 

Rader Programs 

Rogers Memorial Hospital 

Rosewood Ranch 

May 27, 2009 

Internal Revenue Service 

U.S. Department of the Treasury 

Employee Benefits Security Administration 

U.S. Department of Labor 

Centers for Medicare & Medicaid Services 

U.S. Department of Health and Human Services 

Re: Request for Information Regarding the Paul Wellstone and 

Pete Domenici Mental Health Parity and Addiction Equity Act 

of 2008 (published in 74 Fed. Reg.19155 et seq.) 

VIA EMAIL: E-OHPSCA.EBSA@dol.gov

To the Departments: 

The Eating Disorders Coalition for Research, Policy & Action 

(EDC) welcomes the opportunity to respond to the request for 

information as you begin the rulemaking process on the Paul 

Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (MHPAEA). In this letter we 

first underscore the importance of considering regulatory 

language that ensures eating disorders coverage is not 

specifically excluded. Second, we offer answers to a number 

of the specific questions as requested. 

The statutory language of the MHPAEA should prevent an 

employer from evading the spirit of its parity requirement by 

creating new, additional, or other restrictions for mental 

health/substance use benefits. Thus, we urge that a central 

consideration in regulatory implementation be clear guidance 

that prohibits employers and insurance companies from 

specifically excluding eating disorders coverage. 

Eating disorders are complex biopsychosocial illnesses with 

the highest mortality and morbidity rate of any psychiatric 

diagnosis. They are the third most common serious illness 

affecting adolescent females, after diabetes and asthma. 

According to the newest genetics research, more than 50% of 

all of the factors that cause eating disorders are inherited. This 

heritability rate is comparable to what has been found among 
other illnesses like schizophrenia and bipolar disorder both of which are commonly included in 

coverage without dispute. 

When eating disorders treatment is cut short due to insurance limitations, recovery is temporary 

or partial which leads to a revolving door phenomenon with people returning for treatment over 

and over again. This trend increases the overall cost of care and threatens lives. Between 1985 & 

1998 readmissions of eating disorders patients have increased steadily as length of stay has 

become briefer and weight at discharge has been lower (Halmi et al., 2000). Shorter periods of 

treatment for eating disorders are associated with less successful outcomes (Commerford, Licino, 

& Halmi, 1997). Yet relative to other accepted medical interventions, the treatment of eating 

disorders when done adequately and comprehensively are cost-effective and, in fact, quite 

reasonable (Crow and Nyman, 2004). 

Lastly, when done well, treatment works. In one study where patients were followed for 5-10 

years, approximately half of the sample had recovered, 25% improved with some residual 

symptoms, and only 25% remained ill or died (Garfinkle, 1995). 

In summary, comprehensive eating disorders treatment is financially a sound investment and 

most importantly, in keeping with the spirit of mental health parity, leads to improved health 

outcomes. 

Now we address the following questions posed in the request for information. 

Do plans currently impose other types of financial requirements or treatment limitations on 

benefits? How do plans currently apply financial requirements or treatment limitations to (1) 

medical and surgical benefits and (2) mental health and substance use disorder benefits? Are 

these requirements or limitations applied differently to both classes of benefits? Do plans 

currently vary coverage levels within each class of benefits?

The answer is different for every single insurance plan available, so this is difficult to 

answer. We do know that there are unequal restrictions on mental benefits versus 

medical benefits. An example is seen in the coverage of nutrition therapy. Most 

insurance companies currently cover nutritional visits for someone who is diagnosed 

with obesity and/or diabetes. However, people with eating disorders do not get nutritional 

visits covered or if they do it is for a handful of visits (like a maximum of three). This 

makes the financial burden of recovery for those diagnosed with eating disorders higher 

and threatens recovery. Since eating disorders are illnesses with serious medical and 

nutritional consequences, nutritional rehabilitation is a critical aspect of successful 

recovery requiring regular follow-up for months or years. 

What terms or provisions require additional clarification to facilitate compliance? What specific 

clarifications would be helpful?

Clarification is necessary regarding when state laws are to be preempted or not. It is 

particularly important that stronger state laws that specifically enumerate the coverage of 

eating disorders either explicitly or through general parity laws (they include all mental 

illnesses in the DSM-IV) remain in effect and are not trumped by the federal law. 

What information, if any, regarding the reasons for any denial under the plan (or coverage) of 

reimbursement or payment for services with respect to mental health or substance use disorder 
benefits is currently made available by the plan? To whom is this information currently made 

available and how is it made available? Are there industry standards or best practices with 

respect to this information and communication of this information? 

Information regarding reasons for denial is very difficult to obtain by the consumer. 

Typically when a consumer calls to request coverage they speak with a "plan specialist" 

who details benefit coverage in a “Swiss Cheese method” where they receive an 

overview of coverage but much of the critical information is missing. The consumer 

must then call multiple times to try and fill in the 'holes'. It is not unusual to call 

insurance companies and speak with five different people trying to obtain their 

definitions of "medical necessity” and receive five different answers. It is nearly 

impossible for the consumer to get a hard copy of these definitions. Oftentimes the 

standard response is, "That is not something I have access to." We know of families who 

have tired for more than two years to obtain definitions of coverage. 

The consistent failure to provide adequate information to consumers produces stress and 

dissuades people from seeking much needed treatment. In addition, failure to provide 

clear and direct access to this information has resulted in bankruptcy for some of those 

seeking treatment yet they believed their benefits were quoted to them correctly. Later 

they found out that they were not provided accurate information and complete full 

disclosure of their benefits. 

To gather more information on the scope of out-of-network coverage, the Departments are 

interested in finding out whether plans currently provide out-of-network coverage for mental 

health and substance use disorder benefits. If so, how is such coverage the same as or different 

than out-of-network coverage provided for medical and surgical benefits? 

Definition of out-of-network varies from plan to plan and in some cases, within the plan, 

out-of-network coverage varies from diagnosis to diagnosis. Out-of-network coverage is 

typically much less in both dollar amount and in days covered. A major treatment 

limitation in relation to eating disorders is out-of- network coverage even when the only 

treatment available is out-of-network. For example, Michigan does not have a 

specialized eating disorders treatment center and insurance plans do not cover treatment 

outside of the state. A person who needs specialized care cannot receive it due to this 

restriction. 

Thank you for consideration of our views in your rule making process. We look forward to 

supporting you further in the next steps of your implementation of this vital law. 

Sincerely, 

Jeanine C. Cogan, Ph.D., Policy Director 

Eating Disorders Coalition for Research, Policy & Action