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."
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