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 meds. 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. With the former, you pay less in premiums but more out-of-pocket for medical care and prescriptions before your insurance kicks in to cover eligible costs.
In traditional low-deductible plans, you pay higher premiums, but the carrier covers a copay or coinsurance on your office visits and certain prescriptions. Your deductible is tapped only for services like surgery, emergency room visits, MRIs, and so on. Under these plans, you typically copay for medication and therapy sessions.
[Free Download: What to Ask Before Starting ADHD Medication]
Drawbacks of High-Deductible Plans for ADHD Patients
The higher your deductible, the lower your premiums. For people with ADHD, this is usually not the best option. (However, if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), a high-deductible plan may be worthwhile because it will let you set aside pre-tax dollars for certain health care costs. More on that below.) Generally, high-deductible plans are not advised for these reasons:
- You’re unlikely to put the money saved from lower premiums toward your health care. Also, many folks with ADHD are reluctant to seek routine health care. If they must pay out-of-pocket to see a provider, their motivation won’t improve.
- You may avoid preventive care and end up spending more in the long run. A copay-based system generally helps you to spend less on medical care and keeps you healthier.
HSA vs. FSA
Many employer-based insurance plans offer these options. HSAs are attached to high-deductible plans. If you contribute more than you spend on health care costs in a year, you can roll those funds over year after year and build a sizable nest egg.
FSAs, on the other hand, do not typically roll over to the next year; you must spend the funds during the policy year or lose them. But if you have a sudden expense early in the year, you can typically pay for it with an FSA because these accounts are usually fully funded at the beginning of the policy year (then paid back over the next 12 months through an employee’s pre-tax payroll deduction). By contrast, the HSA can pay only what has been saved.
[Free Resource: Treatment Strategies You Haven’t Tried]
Prescription Discount Programs and Medication Discount Cards
Before you start any brand name medication for ADHD (or anything else), go to the manufacturer’s website and see if they offer a discount program (find a list at additu.de/medsavings). This is not the same as an after-market coupon, like GoodRx. Those can be helpful too, but typically only for generics.
How Does Health Insurance Work: Next Steps
- Free Webinar: How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle
- <Read: Doing Battle with Your Insurance Company
- Read: Can Insurance Companies Discriminate Because of ADHD?
- Find: ADDitude Directory — Affordable Care Near You
Wes Crenshaw, Ph.D., is a licensed psychologist in Kansas and co-author of ADD and Zombies: Fearless Medication Management for ADD and ADHD.
SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.
