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 mental illness may also have a negative effect on relationships, self-esteem, and result in addictions. 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, and substance abuse during pregnancy, exposure to toxins in early childhood, and brain injuries.
Though often perceived as over-diagnosed, ADD and ADHD truly affects 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 & Individual Health Insurance
Adults with ADHD, or applicants with children affected by this condition will require additional consideration when applying for an individual health plan. As ADHD has often been deemed a pre-existing condition, you may experience an increase in rates or even a full decline. This varies from one insurer to another, yet typically depends on the medication you take, if any, and usually circumstances worsen for those on multiple prescriptions. While children will never be declined for coverage, as federal law prevents insurers from doing so based on health, a plan member under age 18 may have their rates increased.
Also when choosing a plan, you should make sure the benefits include mental health care. Many plans still do not cover such treatment, including the regular meetings with psychiatrists a person on 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, otherwise purchasing a plan may not be much help for the condition. Mental health care 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.
For an example of how underwriting works for one company in particular, here is a look at a health plan’s current guidelines regarding ADHD. This carrier has one of the more easily understandable underwriting manuals, and also slightly less strict policy for conditions than others. Keep in mind this is an example, not a universal answer for all companies in all areas. This insurer favors ADD applicants who have been medication and treatment-free for at least one year, and will adjust rates to a miniscule degree or not at all for such cases. If you do take medication, there is the potential of paying double the amount of a normal premium, or being declined altogether.
Other Health Plan Options for ADD/ADHD
In the event that you have been declined coverage due to your ADD, there are other possibilities for health insurance. Those who have the ability to obtain group health insurance through an employer will not be declined, and certain plans cover mental health care. There is also the option of PCIP, the Pre-Existing Condition Insurance Plan, which will help you pay for medications as well as mental health benefits. Low-income individuals with ADD may be able to qualify for coverage through a state or federally funded assistance program, such as Medicaid. Depending on your age, income level, and insurance, you have access to coverage if individual health insurance has not worked out.
Medicaid & CHIP
If you have a very low income and have a family, public assistance for health insurance 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 care nonetheless. If you have a preferred doctor, find out if they are a participating Medicaid provider beforehand.
CHIP is a program to cover 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. While there is a waiting period before coverage begins, employer-sponsored plans do not turn anyone away for health problems or pre-existing conditions. 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. In the meantime, short-term health plans are a nondiscriminatory source while waiting for group benefits to become effective.
PCIP
Established several years ago by the Affordable Care Act, PCIP is a temporary high-risk pool offered to people who have been turned down by insurers for their health. PCIP will price plans according to your income and age, not your health. These plans require an individual not have any health insurance for at least six months before applying. Once enrolled, you have immediate access to coverage, and no exclusions will be made related to your condition. Many individuals with ADD have sought out PCIP as a source of coverage over the past few years.
Health Reform and Attention Deficit
The healthcare law should have a positive impact on individuals with ADD and ADHD, as mental health benefits are becoming a requirement. When the law goes into its next stages of implementation in January 2014, mental health care will be required by private health insurers for both individual and group plans. This means those who have benefits through their job will have access to coverage for therapy, as well as those who apply for an individual health plan. One of the most important provisions of the law requires the individual market to accept all adults with pre-existing conditions regardless of their health.
There will be no adjustments in rates based on a person’s illness, and insurers cannot issue exclusion periods or elimination riders any longer in 2014. Health reform also offers the option of expanding a state’s Medicaid program to include adults without children or disabilities. The states who choose to implement Medicaid expansion will be providing adults with income up to 138 percent FPL with free health insurance coverage. Also, those who are in between Medicaid poverty level and being able to afford a health plan will receive assistance to pay premiums with subsidies from the government. Most importantly for people with ADD is the inclusion of mandatory mental health care.
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