Insurance and Public Benefits
Because ADHD can pervade almost every aspect of an individual’s life, many systems can come into play in the life of a person or family affected by the disorder.
The Insurance System
The majority of Americans who have health insurance receive this coverage through employer-provided health insurance plans. Millions of Americans, however, do not have private health insurance, relying primarily on public programs to pay for health services.
Passage of the Affordable Care Act (ACA) in March 2010 began a multi-year process implementing significant changes to the health care system in the United States. For more information on ACA and how it may affect you and your family now or in the future, see About the Law.
Prior to 2008, mental health treatment was not always paid for at the same rate as other health care costs. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act of 2008 requires healthcare plans that offer mental health coverage to provide equitable coverage of medical, surgical, mental health and addiction benefits. The law makes it illegal for health insurance plans sponsored by businesses with 50 or more employees to impose day and visit limits that are more restrictive than physical illness coverage. It also prohibits applying different deductibles, copayments, out-of-network charges and other financial requirements for mental health treatment compared to physical health treatment covered in a plan.
Paying for Medications
Paying for prescription medications can be a challenge for anyone with a chronic condition. This challenge may be faced both by those who have health insurance as well as those who do not. Those with health insurance may have policies that do not include prescription drug coverage, or their drug coverage may have restricted formularies, high deductibles, high copays or other limitations which increase out-of-pocket expense. For those without insurance, the problem is even worse.Individuals who face the challenge of being able to afford medications are not without options. Below are several suggestions if you or a member of your family is unable to afford the ongoing cost of prescription medication.
State Pharmaceutical Assistance Programs
As of May 2009, 38 States have enacted laws to create some form of pharmaceutical assistance programdesigned to help those who are unable to afford prescription medications, but who do not meet the eligibility criteria for Medicaid. By April 2009, 32 states had such programs already in operation. In early 2009, no fewer than 42 states had authorized or established some form of assistance providing pharmacuetical assistance or coverage. While many of these programs focus on helping the elderly, they also offer assistance to individuals with disabilities. The National Conference of State Legislatures provides a helpful chart summarizing these programs, with contact information for each.
Pharmaceutical Patient Medication Assistance
Some pharmaceutical manufacturers offer assistance in helping to cover the cost of prescription medications. They may do this either through a Medication Assistance Program for a particular medication, or through a discount card that provides varying degrees of discounts on selected medications. Information on these programs and discount cards may be found through the following sites:
- NeedyMeds.org – A non-profit with the mission of helping people who cannot afford medicine or healthcare costs.
- RxAssist – A national program from Volunteers in Health, funded through private foundations, like the Robert Wood Johnson Foundation, through corporate sponsorships such as Express Scripts and also from private donations.
- Partnership for Prescription Assistance – The PPA is sponsored by America’s pharmaceutical research companies. (Also known as HelpingPatients.org)
CHADD Discount Prescription Card
CHADD has developed a Medical Benefit Program designed to help those with or without insurance reduce the cost of paying for prescription medications.
Private Health Insurance
The majority of Americans who have health insurance receive private insurance coverage through employer-provided health insurance plans.One type of plan is a standard indemnity policy, which gives people freedom to visit a health care provider of their choice and pay out of pocket for their treatment. The insurance plan reimburses members for some portion of the cost. The other common plan is a managed care plan. Under this plan, medically necessary care is provided in the most cost effective—or least expensive—way available. Plan members must visit health care providers chosen by the managed care plan. Generally, a co-payment is charged to the patient, but sometimes all care received from providers within the plan is covered.
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 the office of your state government to see what external grievance and complaint procedures may exist in your state.
Public Health Insurance
Medicaid is a jointly funded, federal-state health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled and people who are eligible to receive federally assisted income maintenance payments.
Within broad national guidelines that the federal government provides, each of the states establishes its own eligibility standards; determines the type, amount, duration and scope of services; sets the rate of payment for services; and administers its own program. Thus, the Medicaid program varies considerably from state to state, as well as within each state over time. The Centers for Medicare & Medicaid Services offers a wealth of information and a directory of state Medicaid offices on its website.
Medicaid Buy-In (Ticket to Work)
Through the landmark legislation, “Ticket to Work and Work Incentives Improvement Act of 1999,” individuals with disabilities no longer have to choose between taking a job and having health care. Individuals with disabilities who work and do not meet Medicaid eligibility criteria may buy into the program.
Like the Medicaid program, eligibility for the Ticket to Work program varies from state to state.
SCHIP (State Children’s Health Insurance Program)
The U.S. Department of Health and Human Services has launched the Insure Kids Now! campaign to link the nation’s 10 million uninsured children to free and low-cost health insurance.
Every state has a health insurance program for infants, children and teens whose families do not qualify for Medicaid. Many families simply don’t know their children are eligible.
The states have different eligibility rules, but in most states, uninsured children 18 years old and younger, whose families earn up to $34,100 a year (for a family of four) are eligible.
Supplemental Security Income (SSI)
SSI is a federal benefit program administered by the Social Security Administration (SSA). It provides monthly payments to people who are at least 65 years old, or blind or disabled and is reserved for people with severe, chronic conditions and great financial need. Children with ADHD up to age 18 who meet strict disability and income requirements may be eligible for SSI. For a disabled child, the program can provide the following:
- monthly cash payments based on family income
- qualify your child for Medicaid health care services in many states
- ensure referral of your child into the system of care available under State Title V programs for Children with Special Health Care Needs (CSHCN)
For children with ADHD to be considered disabled for SSI purposes, their ADHD must very seriously limit their daily functioning and be present (or be expected to last) for at least 12 months. Most children with ADHD who qualify as having a disability for SSI usually have co-existing conditions along with their ADHD. In addition, children and their families must have very low incomes and few resources. Therefore, the majority of children with ADHD will not qualify for SSI.
If you decide to pursue SSI for your child with ADHD, you will be asked to provide your child’s birth certificate and Social Security number and financial information. SSA will want detailed information about your child’s condition and functioning from family members, teachers, doctors, counselors and others who know, work with, or care for him or her. If your child is approved for SSI, his or her information will be reviewed every three years to determine if he or she still meets the disability and income eligibility requirements. For more information on SSI, visit the Social Security Administration’s Supplemental Security Income Benefits webpage and/or review Social Security: Benefits for children with disabilities or contact your local Social Security office.
Social Security Disability Insurance (SSDI)
Social Security Disability Insurance pays benefits to you and certain members of your family if you are disabled and unable to work, and if you are “insured” (meaning that you previously worked long enough and paid Social Security taxes). SSDI has strict eligibility requirements that must be met. For an adult, eligibility requires that an individual must be unable to perform any “substantial gainful activity” (SGA) due to a physical or mental impairment that will last for a period of at least 12 months.
The process to apply for SSDI involves several steps that address the following issues:
- current work status
- severity of the condition
- is the condition on the list of “disabling impairments”
- can you do the work you previously did
- can you do any other type of work
Adults with ADHD can qualify for disability benefits but only in cases where they can prove that their ADHD prevents them from performing substantial gainful work activity. This can be difficult for adults with ADHD to prove.