If your child has been diagnosed with
attention deficit/hyperactivity disorder (ADHD), you'll likely face a
bumpy road of treatment options and results. Add to that the task of
finding appropriate health insurance coverage.
ADHD is a chronic neurobehavioral condition that
can manifest in many ways, including hyperactivity, impulsivity and the
inability to pay attention. These symptoms often lead to difficulty in
academic, emotional and social functioning. According to the National
Institute of Mental Health, ADHD symptoms become apparent in preschool
and the early school years.
According to a 2008 National Health Survey by the
Centers for Disease Control and Prevention, 4.4 million children
between age 3 to 17 have been diagnosed with ADHD by a medical
professional. In addition, ADHD diagnoses among children ages 12 to 17
increased by 4 percent from 1997 to 2006. Stimulants are the most
common type of medication prescribed for ADHD, including Ritalin,
Adderall and Dexedrine. ADHD is generally treated with a combination of
behavioral therapy and medication.
ADHD treatment falls under "mental health treatment" benefits, so if your health insurance
plan doesn't include mental health coverage, you don't have a claim.
Your plan may even specifically exclude coverage of ADHD, so read it
carefully before pursuing a claim.
If you belong to an HMO, your choice of providers
and benefits could be restricted and you may need to run a gauntlet of
pre-authorization requests; without the right pre-authorization before
treatment, your insurance claim could be denied.
The Mental Health Parity and Addiction Equity Act
of 2008 makes it illegal for group health plans (like those offered at
work) to discriminate in coverage for mental health services. Group
plans must offer mental health coverage levels that are equal to
medical treatment coverage levels.
Clarke Ross, CEO for Children and Adults with
Attention Deficit/Hyperactivity Disorder (CHADD), a nonprofit advocacy
group for people with ADHD and their families, points out that ADHD is
treated like most mental health conditions listed in the Diagnostic and
Statistical Manual of Mental Health Disorders (DSM-IV-TR).
"Most plans cover the assessment of ADHD and some
cover the treatment. Prior to the new pre-parity law, there were
significant limitations on assessment and treatment. We are hopeful
that when the national parity requirement goes into effect in October
2009, this will eliminate the limitations that have been historically
applied to ADHD," he says.
He adds that
insurance limitations are far more complex than simply using the mental
health manual to prove that the condition is medically necessary.
"In
a recent survey we found that 82 percent of insurance plans paid for
the initial assessment but restricted who could do the assessment. The
insurance companies had varying parameters on who had the best
credentials to assess if a person has ADHD. Only the authorities they
chose could determine if the treatment of ADHD was medically necessary.
Some plans felt that only a psychologist or psychiatrist had the
authority to assess individuals and others felt that only pediatricians
could make such an assessment. If your plan didn't feel your child was
diagnosed by the right authority, they wouldn't pay for treatment."
Robert
Tudisco, an attorney in White Plains, N.Y., who dedicates a portion of
his practice to advocating for special needs children and people
inflicted with ADHD, says that the mental health parity law doesn't go
far enough.
"Even if you have a health
plan, most insurers impose limits on the amount of coverage they will
allow. Even If your group or individual health plan has a generous
mental health package, there are still limits on maximum allowable
outpatient visits that they will pay for. Even with the new law in
place, some insurers only allow 10 visits per year with a psychiatrist
or psychologist," says Tudisco. "There are also blanket statements in
the law that define what is a discriminatory coverage and what is not
that do not go far enough in explaining what is considered
discriminatory."
The good news is if your health insurance plan
provides mental health coverage, it can't restrict access to ADHD
medication under the Mental Health Parity and Addiction Equity Act of
2008. Here's more about getting mental health treatment coverage for children.
Even so, health insurers err on the side of caution
when it comes to prescription drug treatment for children with ADHD. A
recent study from the American Heart Association found that stimulant
ADHD drugs could pose health risks for children who have abnormal heart
rhythms, and must be closely monitored by physicians.
"The medications used to treat ADHD are effective
drugs, but they can have negative ramifications for people who do not
have the condition. Because these medications are all too often
being prescribed without the necessary evaluations being conducted, we
have implemented coverage guidelines to ensure that those who need
these medications have access to them, and receive the appropriate
screening and diagnostic services," says Dr. Douglas R. Hadley of CIGNA
HealthCare. "In the past year, we have enhanced the coverage to include
screening for ADHD, which has been well-received by both the pediatric
and family-medicine communities."
Most states have already enacted mental health
parity laws, and some states name ADHD treatment in those. These laws
require insurers to cover mental health treatment at equal levels to
physical illness coverage. According to NAMI, Delaware, Kansas,
Virginia and West Virginia have mental health parity laws that
specifically include ADHD coverage.
For a full list, see mental health parity laws by state.
Further compounding the health insurance
situation for parents of children with ADHD is that the condition often
coexists with other psychiatric conditions, sometimes with overlapping
symptoms. The National Resource Center on ADHD, a clearinghouse of
science-based information about the condition, states that two-thirds
of children with ADHD have at least one coexisting condition. The most
common coexisting conditions are:
- Oppositional defiant and conduct disorders
- Anxiety or depression
- Tics and Tourette syndrome
- Substance abuse (among adolescents and teenagers)
- Sleep disorders and learning disabilities
In addition, parents of children with ADHD may hear
about alternative treatments for the condition, which would be used in
lieu of prescription drugs or medical treatment. There may also be
complementary treatments available, which would be used in conjunction
with standard medical treatment. The National Resource Center on ADHD
urges parents to tread carefully before embarking on treatments that
haven't been tested and reviewed by medical experts.
If you decide to go this route, you'll do it at
your own cost: Health insurance won't cover experimental,
investigational or unproven treatments.
For more information about the diagnosis and treatment of ADHD go to www.Help4ADHD.org
Ross notes that while health insurance plans are
becoming more open to the idea of treatment for ADHD in childhood, they
have not accepted the same treatment for adults.
"What's disturbing is the same plans still have a
higher rate of restrictions when it comes to treating adults with
ADHD," he says. "There is this notion among health care providers that
once you reached the magic age of 18 you were cured. The science shows
that 80 percent of children will manifest ADHD as adults and health
insurance plans with adults have not caught up with the science yet."
Ross adds that a number of professional medical
associations have created evidence-based assessments, treatment and
guidelines for ADHD in children, but have overlooked what happens to
those children in adulthood.
"There is still no comparable standard for adults
with ADHD, and payers are reluctant to pay when there isn't
professional assessment with evidence-based standards for treatment.
This remains an uphill battle for us," he says.
If your child has been diagnosed with ADHD, take
advantage of all the resources available from your health insurer.
According to Robert Zirkelbach, spokesperson for America's Health
Insurance Plans, a trade association, "Health plans have a number of
tools available today to assist individuals with behavioral health
conditions, including prescription management, health coaching,
employee-assistance programs and a variety of Web-based support tools."
