ADHD in a Managed Care Context

Succeeding in today’s health care system

The majority of Americans with health insurance get their healthcare through managed care organizations (MCOs). Managed care is a health care system that coordinates and provides health benefits for its members. The most common types of MCOs are:

Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
Exclusive Provider Organizations (EPO)

Each insurer has its own set of rules. As a result, it is crucial to understand how they work when getting a child evaluated for ADHD. Patients need to need to read their member information carefully.

While the various types organizations may differ, many processes are common to all MCOs.

Mental Health Benefits

Most MCOs offer a mental health benefit to their members. Many outsource their mental health coverage to an outside company to manage. These benefits usually include:

Evaluations
Crisis intervention
Treatment of documented conditions

The treatment options including therapy and medications often vary based on the type of coverage you have. To access these mental health services, some plans require approval or referral from a Primary Care Provider.

Primary Care Providers: Doctors, Physician Assistants, and Nurse Practitioners

The Primary Care Provider (PCP) is often the starting point of evaluations for ADHD. A child’s PCP is usually a:

Doctor (pediatrician, family doctor)
Physician assistant
Nurse practitioner

This clinician will most likely have received formal training on how to diagnose ADHD. Your PCP will usually conduct an evaluation. You may be referred to a psychiatrist or other mental health specialist if needed.

Medications

When a person is diagnosed with ADHD or any condition requiring medication, the PCP will often recommend medication and/or behavior management. There are a variety of medications that are used for ADHD.

Drug Formulary

The type of medication allowed may need to be chosen from the health plan’s formulary. Formularies are lists of medications that doctors, pharmacists, and other experts have determined are the best treatments. They are updated frequently to include newer drugs. The patient pays a different co-payment depending on the tier. Many MCOs use a 3-tier system for drugs:

Tier 1: Generics: Non-brand name drugs. These are typically the most inexpensive for the HMO. They are the lowest cost for patients.
Tier 2, Preferred Brands: Brand name drugs that the health plan chooses to include in its coverage. These are more expensive than generics for patients, but are not the most expensive drugs.
Tier 3, Non-preferred Brands: These are the most expensive brand name drugs. They cost the most for both MCOs and patients. As a rule, tier 3 drugs have acceptable alternatives in tiers 1 and 2.

Health plans use tiers to encourage people to use more cost-effective versions of drugs. It is important to read any updates the MCO sends you or has posted on their website because formularies vary widely between health plans and change frequently.

It is important to spend time understanding how the health care system works. Your benefits and coverage may change from time to time. Contact someone at your MCO office if you have questions about your member benefits.