Eating disorders and how they are treated

According to the National Institute of Mental Health (NIMH), eating disorders include:

• Anorexia nervosa — People with this condition see themselves as overweight even when they are dangerously underweight, so they may avoid or severely limit what they eat. They may also have binge-eating and purging episodes.
• Bulimia nervosa — People with this condition have recurrent, frequent episodes of binge-eating unusually large amounts of food followed by forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise or some combination of these behaviors.
• Binge-eating disorder — People with this condition, which is the most common eating disorder in the U.S., have reoccurring episodes of eating unusually large amounts of food in a short period. They do not follow that activity with the compensating activities that those with bulimia nervosa undertake.
• Avoidant restrictive food intake disorder — People (typically children) with this condition, which was previously known as selective eating disorder, limit the amount or type of food eaten. Unlike those with anorexia nervosa, people with this condition do not perceive themselves as being overweight.

Eating disorders are treated with nutritional counseling, behavioral therapy, prescription drugs and/or residential treatment programs.

Mental health parity requirements and previous guidance

In 2016, the 21^st Century Cures Act clarified that eating disorders are mental health conditions covered by MHPAEA’s parity requirements. MHPAEA requires group health plans to treat mental health and substance use disorder benefits in a similar way as medical and surgical benefits. Consequently, treatment for eating disorders should be covered in a consistent manner as treatment of medical conditions.

In FAQs 38 and 39, which were published in 2017 and 2019, respectively, the DOL, Department of Health and Human Services and the Treasury (collectively, the Departments) discuss application of the 21^st Century Cures Act in the context of the MHPAEA requirements. The Departments point out that coverage restrictions based on facility type are nonquantitative treatment limitations (NQTLs), which may be applied no more stringently for mental health/substance use disorder benefits than for medical/surgical benefits. For example, the Departments cautioned that if a restriction on inpatient non-hospital residential treatment for eating disorders is more stringent than the restriction on inpatient treatment outside a hospital for medical/surgical conditions, such restriction on the treatment of the eating disorder would not comply with MHPAEA. 

The Departments continued to address coverage for eating disorders in their July 2023 Report to Congress, which noted that many plans have impermissible exclusions of key mental health/substance use disorder (MH/SUD) treatment, including nutritional counseling to treat mental health conditions, such as eating disorders.

The latest guidance

In the latest statement on eating disorders, EBSA Assistant Secretary Lisa Gomez writes that people seeking treatment for eating disorders, such as therapy, medications, nutritional counseling, or residential treatment programs, should not face barriers or roadblocks that do not exist for medical treatments. Gomez provides this example: “[I]f a health plan provides coverage for nutritional counseling for someone with diabetes, it cannot have a blanket exclusion for coverage of nutritional counseling for those with eating disorders.”

Implications for plan sponsors

Eating disorder coverage is clearly a major enforcement initiative for the Departments’ implementation of MHPAEA. The Departments have stated they will look closely at residential treatment limitations, as well as therapy and nutritional counseling restrictions for eating disorders, to ensure that patients do not face barriers to treatment for these conditions.

As plan sponsors review their plans for compliance with MHPAEA, they should be sure to examine any limitations that could be an NQTL or exclusion on treatment for eating disorders and ensure that the limitations are no more stringent for eating disorders than medical/surgical conditions. Plans that provide nutritional counseling for medical/surgical conditions should provide comparable counseling for MH/SUD conditions as well.