How Does Health Insurance Work? A Primer for ADHD Patients

Understanding health care coverage is a prerequisite for good ADHD treatment.

Health insurance is like the weather: You don’t think about it until it rains on your parade. To treat your ADHD properly, you should understand your insurance plan because it exerts the greatest influence over how you manage your medications. Here is a primer to get you started.

Health Insurance Plans: High-Deductible vs. Low-Deductible

Employer-sponsored health plans generally include high-deductible plans and low-deductible plans.

High-Deductible Plans

Premiums: Lower monthly costs.
Out-of-Pocket Costs: Higher initial costs for medical care and prescriptions until your deductible is met.
Best For: Individuals who rarely seek medical care and have savings to cover unexpected expenses.

Low-Deductible Plans

Premiums: Higher monthly costs.
Out-of-Pocket Costs: Lower costs at the time of service, with copays or coinsurance for office visits and certain prescriptions.
Best For: Individuals with chronic conditions like ADHD who require regular medication and therapy sessions.

Drawbacks of High-Deductible Plans for ADHD Patients

Motivation: ADHD patients might be less inclined to seek routine care due to higher out-of-pocket costs.
Preventive Care: Avoiding regular check-ups and preventive care can lead to higher long-term costs and worsened health outcomes.
Financial Planning: Without structured savings, the lower premiums do not necessarily translate to better financial management of health care expenses.

Health Savings Accounts (HSA) vs. Flexible Spending Accounts (FSA)

Health Savings Accounts (HSA)

Eligibility: Must be paired with a high-deductible health plan.
Rollover: Funds can roll over year to year, allowing for long-term savings.
Tax Benefits: Contributions are pre-tax, and the account can grow over time.

Flexible Spending Accounts (FSA)

Eligibility: Available with various types of health plans.
Rollover: Typically, funds must be used within the policy year or be forfeited.
Funding: Accounts are fully funded at the start of the policy year, which can be advantageous for early-year expenses.

Understanding ADHD Treatment Coverage

Medication Coverage

Formulary Lists: Check your insurance plan’s formulary list to see which ADHD medications are covered. Medications on this list are usually more affordable.
Prior Authorization: Some ADHD medications may require prior authorization from your insurance provider. This means your doctor must justify the medical necessity of the medication.
Step Therapy: Some plans implement step therapy, requiring you to try less expensive medications before approving more costly treatments.

Therapy and Counseling

In-Network vs. Out-of-Network: In-network providers usually cost less. Check your plan’s directory for covered therapists and counselors.
Session Limits: Some plans may limit the number of covered therapy sessions per year. Be aware of these limits and plan accordingly.

Prescription Discount Programs and Medication Discount Cards

Manufacturer Discount Programs

Before starting any brand name medication for ADHD, visit the manufacturer’s website to check for discount programs. These can significantly reduce the cost of medications.