Are You Experiencing AD/HD Treatment Coverage Problems in Health
Insurance?
Published in Attention! , December 2002
By E.
Clarke Ross, D.P.A.
During the past year, I have received a variety of calls from CHADD
members whose health insurance companies declined payment for the
treatment of AD/HD. Unfortunately, because of CHADD's small national
staff, we do not have the resources to personally advocate for
individual citizens pursuing claims or complaints. However, we do try to
be helpful by offering generalized advocacy responses to questions
received. This article highlights some of the stories recently brought
to our attention, along with responses we have provided in return.
Evidence-Based Science is the Best Advocacy Strategy
One of the most memorable stories CHADD received about insurance
discrimination came from a Maryland CHADD member and practicing
psychiatrist who complained that Care First Blue Cross/Blue Shield of
Maryland, which covers the assessment and treatment of AD/HD, denied, as
medically unnecessary, traditional psychotherapy for the treatment of
AD/HD. In response, CHADD contacted the American Psychiatric Association
(APA) and the American Academy of Child and Adolescent Psychiatry
(AACAP) for support. Together we approached BC/BS of Maryland. We shared
with BC/BS the findings of the Surgeon General's Report on Mental Health
and the National Institute of Mental Health (NIMH) Multi-modal Treatment
Study (MTS). We obtained and shared published studies from our
Professional Advisory Board (PAB). AACAP shared their best practice
guidelines. APA took the lead and consistently contacted BC/BS. We also
stated that if this practice wasn't modified, we would consider moving
forward with both the state's legislature and local media. [BC/BS,
regulated by the state, is being sold to an out-of-state for-profit
organization.]
Following six months of persistent advocacy on our collective parts,
BC/BS ultimately changed their policy so that "short-term cognitive or
behavioral psychotherapy for individual and family sessions for AD/HD"
is now considered "medically necessary." Most states publicly list a
health insurance company's medical necessity coverage policies through
the Internet. Citizens and health plan enrollees should check these
policies. (See the BC/BS of Maryland policy online.
In another incident, a CHADD member contacted us to report that
S&S Health of Alabama denied treatment of AD/HD for all persons over
the age of 19 years. We shared the CHADD fact sheets on adults with
AD/HD and encouraged the individual to use the health company's internal
appeals process to challenge this denial.
In a similar situation, a CHADD member in his forties contacted us
with complaints that BC/BS of Maryland had denied payment for his
stimulant medication. We provided the CHADD fact sheet on adults with
AD/HD and encouraged him to use the company's internal appeals process
to challenge this denial. Though he opted to incur the first month's
cost himself, as he did not want to wait, his appeal was ultimately
successful and today BC/BS is paying for his medication to treat
AD/HD.
Inconsistent Coverage Is Typical
Several months ago, a Ph.D. child psychologist contacted us to
complain that BC/BS of Texas and its mental health vendor, ValueOptions
(VO), denied payment for the assessment of AD/HD because VO would only
pay for assessments by child psychiatrists. CHADD contacted the chief
medical director of VO and VO changed their Texas policy. The Texas
policy was inconsistent with their national policy.
The June 2001 issue of ATTENTION! included an article on the
treatment of AD/HD within a managed care program operated by United
Behavioral Health (UBH). UBH data from 104 different employer health
plans was analyzed for the assessment and treatment of a sample of 2,137
children with AD/HD. An Iowa hospital contacted us to say that UBH of
Iowa did not cover the assessment and treatment of AD/HD. We responded
by encouraging the hospital to contact UBH nationally.
Lack of Mental Health Parity
Mental health parity is a legislative/regulatory requirement
prohibiting health insurance from discriminating on the basis of mental
disorders. Under parity, mental and physical disorders would have to be
equally covered. [See CHADD's Position Paper, Where We Stand - Mental Health Parity.]
A CHADD member from York, Pa., contacted us with complaints that
BC/BS denied payment on outpatient treatment for AD/HD after 20 visits
annually and required a 50percent co-payment for AD/HD rather than the
20percent co-payment for physical disorders. Another CHADD member from
Oklahoma, notified us that that BC/BS denied any coverage of AD/HD. A
CHADD member from Colorado called to report that while group health
insurance policies covered AD/HD, individual policies denied the
coverage of AD/HD. Unfortunately, all these coverage policies are
legal.
All three states (Pa., Okla., Colo.) have state legislation requiring
parity for mental disorders. But these three states mandate state parity
only for group plans and for persons with "serious mental illnesses,"
most frequently defined as persons with schizophrenia, bipolar disorder,
major depressive disorder and other similar illnesses. Health insurance
companies are free to define mental disorders as they wish. We suggested
that the Colorado and Oklahoma CHADD members review the policies
provided by the Maryland BC/BS - at least they could point to other
health insurance plans in America that cover AD/HD.
Advocacy Resources
All health insurance companies have internal grievance and complaints
procedures. If you have a complaint, follow the company's procedures.
All states have a state health insurance commissioner. Contact that
office of the state government to see what external grievance and
complaint procedures may exist in your state.
The most helpful national advocacy resource is the National Health
Law Program. Contact their web site to learn which states have ombudsman and
consumer assistance programs along with access information on state
health insurance consumer protections. This site also provides
information on choosing an appropriate health insurance plan and
information on which states have pharmacy assistance programs (programs
that sell prescription medications at costs less than market price for
those without or with limited insurance).
Health Insurance Does Not Pay for IDEA Special Education and Related
Services
Ever since the enactment of the Individuals with Disabilities
Education Act (IDEA) in 1975, health insurance has consistently
declared: "Benefits are not provided for diagnostic or treatment
services related to learning, curriculum planning, educational
achievement or special education programs provided under IDEA of Section
504 Plans." This is BC/BS of Maryland language, but is typical of such
prohibitions throughout the health insurance industry. Many health
insurance plans do cover the assessment and treatment of AD/HD. The
boundary between the two policies remains a continuing challenge.
Health insurance is an enormously complex issue. And while CHADD does
not have the ability to assist individuals experiencing health insurance
discrimination and problems, we hope that this article provides some
important clues and guidance in assisting you with your health insurance
situation.
E. Clarke Ross, D.P.A., is CHADD's CEO
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