ADD/ADHD and Health Insurance

Attention deficit disorder (ADD) and attention deficit hyperactive disorder (ADHD) are common conditions that affect children and adolescents, and may continue into adulthood for some individuals. According to the National Institute of Mental Health (NIMH), an estimated 3 to 5 percent of children have ADHD, and it is questioned whether a child can actually outgrow the condition. Children who have ADHD tend to have difficulty paying attention or focusing. They are unable to follow directions and are easily bored or frustrated with tasks, usually moving frequently and acting impulsively.

Adults who have ADHD may struggle with organization, time management, goal setting and keeping jobs. This illness may also have a negative effect on relationships and self-esteem. The root of ADHD remains unknown, despite continual medical and pharmaceutical research. It may derive from genetics, a chemical imbalance or changes in the brain causing the area controlling attention to be weakened in persons with ADHD. Other potential causes or factors that can cause ADHD to worsen include poor nutrition, infections, substance abuse during pregnancy, exposure to toxins in early childhood and brain injuries.

Though a considerably over-diagnosed condition in psychiatry, ADD and ADHD does affect certain adults and children. Treatment is similar to other neurological disorders, often including a combination of medication and psychosocial therapy. A number of medications in the stimulant family are used to control impulsive behavior and increase attention span, as well as non-stimulants for those who experience negative side effects. These can be very expensive, as certain drugs do not have a generic equivalent, which may result in difficulty obtaining health insurance.

 

ADD/ADHD and Individual Health Insurance: Past and Present

PRESENT

Health Reform and Attention Deficit Disorders

Since the Affordable Care Act has changed underwriting guidelines for every insurer in the United States, ADD/ADHD no longer prevents anyone from getting insured. However, not all policies and insurers will cover treatment and medication. When choosing a plan, you should try to make sure it includes mental health care, which is an essential health benefit category. This means that every state can require all insurers to cover mental health care, yet it remains optional and varies by region.

Some plans may not cover such treatment, including the regular psychiatrist visits that ADHD medication requires. It is also essential to check the formulary to see if the drugs you or your child are prescribed will be covered, though there are no guarantees that any insurer in your state will pay for them. Mental health coverage is different in every state, with each carrier. Check the plan’s details and benefits prior to making a decision so you know how much to expect to pay for the services you need.

In the states that choose to cover mental health care, and in policies sold through exchanges, patients with ADD/ADHD will have access to covered services for their condition. This will be a great help, though still don’t expect the exchange to cover every type of care. According to the final Essential Health Benefit rule issued in February 2013, a vague outline of mental health and substance abuse benefits are to be covered. There is no mention of what exact benefits will be covered, but you can be assured that some plans in your state will offer mental health coverage, whether private or on the exchange.

The Department of Health and Human Services projected in a statement that “in total, through the Affordable Care Act, 32.1 million Americans will gain access to coverage that includes mental health and/or substance use disorder benefits that comply with federal parity requirements and an additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections. By building on the structure of the Mental Health Parity and Addiction Equity Act, the Affordable Care Act will extend federal parity protections to 62 million Americans.”

Additionally, ADD and ADHD will not be cause for a rate increase, and insurers cannot issue exclusion periods or elimination riders for your medical history.

 

PAST

Adults with ADHD, or applicants with children affected by this condition will require additional consideration when applying for an individual health plan. As ADD was deemed a pre-existing condition, you would typically experience an increase in rates or even a full decline. This varied from one insurer to another, yet depended on the medication you take, if any. Premiums were usually higher for those on multiple prescriptions. Before 2014, adults and children with this condition could have their rates increased, but only adults could be declined between 2010-2013.

For an example of how underwriting worked for one company, here is a look at a health plan’s 2012 guidelines regarding ADD/ADHD. This carrier had one of the more easily understandable underwriting manuals, and also slightly less strict policy for conditions than others. This insurer favored applicants who had been medication- and treatment-free for at least one year, adjusting rates slightly or not at all in these cases. If you used medication, there was the potential of paying double the amount of a normal premium, or being declined altogether.

 

 

Other Health Plan Options for ADD/ADHD

Those who have the ability to obtain group health insurance through an employer may have access to covered mental health care. If group coverage is unavailable and individual plans are too costly, you may consider Medicaid or a state exchange plan with tax credits and subsidies. Most importantly for people with ADD is the inclusion of mandatory mental health care in these government programs. Depending on your age, income level and insurance, you may have access to coverage if private health insurance is too costly or not offered to you.

Medicaid and CHIP

If you have a very low income and have a family, public assistance is a good option for individuals with ADD. Medicaid eligibility is different in each state, though every program should offer the same comprehensive set of benefits. Mental health care is always covered by Medicaid, as well as prescriptions. You will be restricted to Medicaid-approved providers, though you will be able to receive various types of care.  If you have a preferred doctor, find out if they are a participating Medicaid provider beforehand.

The Children’s Health Insurance Program (CHIP) covers uninsured children and pregnant women whose income is higher than Medicaid, and they will also accept individuals with ADD. As long as you meet the income requirements for subsidized coverage, you will only have to pay a nominal fee for premiums or a small copay for services, though some states require no fees. Others who have a family income over 300 percent of the Federal Poverty Level may also get insured through CHIP for a higher cost. Like Medicaid, CHIP will cover mental health treatment and medications.

 

Group Health Insurance

If you work for a business who supplies their workers with health benefits, it is worthwhile to consider enrollment as a person with ADHD. There is a waiting period before coverage begins, keep in mind, and employer-sponsored plans are not required by the ACA to include essential benefits, such as mental health care as plans on the exchange or some individual private plans do. As all health plans are different, and employers purchase plans through private health insurers, mental health may not be covered. Apply regardless and check the plan’s benefits to make sure you have access to coverage for what you need, especially prescriptions. If your employer does not cover the treatments you need, research the individual plans in your area or apply on the exchange.

 

Resources

Individual Health Insurance Quotes

Medicaid Information

NIMH: ADHD