I've written before about the blunt approach medical insurance and the insurance industry as a whole has when it comes to mental health. However, things do change, and some things have a contribution.
One of the areas that I have become significantly more aware of is the plight of those that are non-neurotypical. This is possibly a new term for many readers and one that they know as different names like ADD, ADHD, & ASD.
The point is that these conditions and others like them are not mental health conditions in themselves. They are neurological in their origin and are how those individuals brains have been made.
Not developed, not changed with vaccines, not behaviour (though it often looks like behaviour), and certainly not something they or their parents had any control over. So stop saying they are broken and crazy; they are not. We are not.
And that's sort of the point; the mental health aspects of those with non-neurotypical brains is mainly symptomatic of the situations they are put in. They are not from the underlying structure of how their brains are. Mental health is a symptom, not a cause.
Why is this not straightforward?
And that's where this all gets confusing. Especially for those outside looking in, including teachers and medical clinicians that are not specifically trained or experienced in these areas of brains. I use brains rather than neurology as we have an issue with defining this well.
While these situations are neurological (how the brain is made and functions), they are diagnosed and managed by Psychiatrists and Psychologists (how the brain behaves and operates)
Think of it like the Neurologists are in charge of the computer hardware. The psychologists are in charge of the computer's operating system. Teachers are in charge of the programs that are installed ;) (i.e. education, school and tertiary)
The problem is that while we can diagnose and manage non-neurotypical brains with neurology and functional and traditional MRI's, it's expensive to do so.
Where Psychology and Psychiatry come in
We know that covering off six questions gives a pretty firm diagnosis indicator for ADHD without any other intervention. That's cheap and easy compared to the cost for a functional MRI scan that starts somewhere north of $2,000.
And this is the issue; these things are easily diagnosed with the same tools the typical Psychiatrist and Psychologist uses for all the other mental health conditions they diagnose and manage. And they also need to be sure that brain isn't impacted by one of many other conditions before they declare that that brain is not neurotypical.
So it gets complex really quickly. And this is the rub when it comes to insurance too. Is that a mental health condition (behaviour), or is it non-neurotypical (hardware)?
Yes, behaviour is trite and far too simplistic; I used it for effect.
The behaviour management / modification is massively expensive for insurers to take on as there is little in the way of quantifiable measures that allow them to manage and limit claims. We see this with the public system. Crisis management is the highest single cost to the system because the rest is essentially not funded.
The latter, the hardware bit, is neurology. If there are genuine investigations into neurology, then the insurers will typically cover this. Exclusions both on the policy and pre-existing conditions excepted.
The problem for the insurers is that the distinction between mental health and non-neurotypical is nuanced and often is challenging to separate. There often are other mental health issues as well. So they take the stance of excluding the whole lot.
Which is not helpful.
But! There are some insurance providers out there that do provide support for those needing to access Psychiatrists and Psychologists. Some are very limited, and some are generally useful.
Let's unpack this for a typical ADHD diagnosis, the more simple of the ones I see with clients and the community. BTW ADD isn't a thing any more; it's been rolled into ADHD as one diagnosis and one 'condition.'
When we look at the process of diagnosis and management for ADHD, this is what is often found:
Diagnosis and management of ADHD:
- GP consult, probably many of them. Let's call it one @$50 with a referral to a psychiatrist (they are the ones that make the formal diagnosis)
- The Psychiatrist is either public (up to a two-year wait as not urgent) or private with a $400 initial consult cost.
- From there, you probably have a second follow up on this for another $250.
- Once diagnosed and the special authority for medication is sorted, there's the specialist prescription at $35 initially.
- From there, you need to either go back to your GP for a follow-up and confirm the ongoing medication approach. Another $50 (or skip this and continue with the Psychiatrist's scripts)
- From there, monthly scripts cost $25 to $35 for the script
- $15 for the pharmacy
- Depending on your specialist and GP, another $50-250 at month three for a check-up and three monthly thereafter. You understand why people move to their GP reasonably quickly.
- If we add that up, assuming no pharmacy subsidy kicks in, the first year out of pocket cost is: $1,265
- For the second year, it's a little better; no psychiatrist, it's a more palatable $580.
- Year three gets interesting though, as the special authority for the meds needs to be renewed. This is another trip to the Psychiatrist, and $250 for that review.
- So alternating $830/$580 per annum ongoing.
This adds up, especially as those with ADHD typically have a more challenging time with jobs and relationships than their financial position.
So what's the insurance response?
Let's assume that you either have cover already or have been able to get cover without exclusion. As a pre-existing condition, it will be excluded most of the time.
AIA: (Including Sovereign)
Excluded under the mental health exclusion; Psychiatric, Psychological and/or neurodevelopment disorders.
However, sleep disturbance investigations are not excluded outright. But the mental health exclusion will trigger if the finding is related to ASD or ADHD. So an initial diagnosis may be gained through this approach. But is likely not to continue to be covered once an ASD or ADHD diagnosis is given.
Old Superior Health:
First/One Psychiatrist appointment to assess mental health.
Old Absolute Health:
Excluded. Anything relating to a Psychiatrist is excluded.
Also, sleep investigations that are not surgical treatment of sleep apnea are excluded.
Excluded, same exclusions as Absolute Health.
Really Old MajorCare:
Excluded for Psychiatrists, but sleep disturbance is not explicitly mentioned in some versions.
This one is interesting, as mental health treatment is excluded. Still, there is provision for mental health consultations up to $500 per year when referred by a registered medical practitioner under the Specialist+ extension.
Accuro also has the Mental Health Navigator option included under their Best Doctors service; this is unique and provides an alternative pathway for review and assessment. It uses a Telehealth service/process. This is restricted to adults over the age of 18.
While being an excellent provider of major medical health insurance, there is no cover for mental health assessments and management as an exclusion.
There is potential cover with psychiatrists when used in conjunction with neurological conditions where a neurologist is involved. There is a need for both to confirm some diagnosis, but it is quite a rare occurrence.
The alternative avenue for this with sleep disturbance investigations is also an exclusion unless surgery for sleep apnea is diagnosed on an existing policy with first symptoms after a date in 2016.
nib: (Including OnePath/ING/ClubLife & Tower)
Ultimate Health and Ultimate Health Max:
Excluded, for Psychiatrists and sleep disorders outright.
However, under the Cancer and Cardiac treatment benefits, Psychiatrists are covered as a consequence of these two types of treatment and within a limited window of time for condition related counselling services and on a prior approval basis.
Excluded for Psychiatrists and sleep disorders
Excluded for Psychiatrists and sleep disorders
Old Major Medical Extra (OnePath):
Excluded for Psychiatrists, but not for sleep disturbance. With the Caveats stated elsewhere here about mental health diagnosis.
UniMed (Including BNZ, IAG, and State)
Of all the providers we have, clients with UniMed's policy documents are the most challenging to read and understand. So don't be surprised if you have trouble figuring these out.
There is a general exclusion, which is repeated across many documents that exclude Psychiatrists and sleep disorders. However, there are plenty of sections that say psychological and psychiatric services are covered.
Your cover with this provider will be related to your specific combination of benefits.
Psychological Counselling Services:
- The Complementary Medical cover under the Care4U option does have a 50% to a maximum of $250 per year benefit for Psychotherapy, which means there is a level of counselling services available under this plan.
- The Primary Care option increases this to 50% of $400 per year.
- The Primary Care Extra option increases this to 50% of $500 per year.
Prescription Costs and Psychiatrists:
- The Hospital Select Surgical Base Plan has no cover.
- Primary Care $5 per script for $35 per annum for prescription charges.
- The UniCare Plan has $20 per script for $120 per annum for prescription charges. With up to $330 per year unfunded medicines. This also includes 3 x $100 consults per year for Psychiatrists after holding cover for five years.
- The UniCare Plus Plan increases to $150 per annum for prescription charges. And increases to 3 x $150 consults per year for Psychiatrists after holding cover for five years.
- The Unicare Advantage Plan increases prescription charges to $240 per year without the per script restriction. This also includes 3 x $150 consults per year for Psychiatrists after holding cover for five years.
- The UniCare MultiCare, Major Surgical Plus, and Health Positive Plans have $300 per annum for prescription charges. Including unfunded medicines. This also includes 3 x $150 consults per year for Psychiatrists after holding cover for five years.
- The Hospital Select Plus has $400 per annum for prescription charges. Including unfunded medicines. This also includes 3 x $150 consults per year for Psychiatrists after holding cover for five years.
- The Surgery Plus Plan includes 3 x $150 consults per year for Psychiatrists after holding cover for five years.
- The UniCare Plus 80 Plan includes 3 x $150 consults per year for Psychiatrists after holding cover for five years. This is an 80% reimbursement plan.
Southern Cross is one of the better providers in this area, shortfalls in others but one of the better ones by comparison for this stuff.
RegularCare & KiwiCare:
Being the same for hospital, specialists and Diagnostic testing, with the RegularCare plan having additional features for Day to Day Care, I'll group these two together. Southern Cross does in much of its documentation too. As this is an 80% plan and having 100% of your costs covered is the desirable approach, I'll discuss these two plans after WellBeing Two, the go-to product with Southern Cross for most people.
The WellBeing Two Plan:
- Includes up to $750 per annum for psychiatrist costs, which is a good part of the private out of pocket costs that will be experienced. Provided the Psychiatrist is an affiliated provider.
The Keeping Well module has a token contribution to psychology, $100 per annum, and is mainly unhelpful otherwise.
- The day to day care aspect has $660 per annum for prescription costs and GP visits, though this would cover $380 for about $300 in premium (early 40s); if you're getting the pharmacy charge waived, then it's going to be more to have the Day to Day care.
- I have asked if this option covers the GP/Specialist scripts charges, I'm waiting on a response to this, and I'll update it when I have an answer.
- For WellBeing One, this plan typically restricts specialists and diagnostic testing related to a hospital admission within six months of that admission. However, concerning Psychiatrists, this plan doesn't specify the associated eligible treatment requirement, so it looks like this would respond in the same way as its big brother WellBeing Two.
With RegularCare and KiwiCare:
- these plans are an 80% of costs approach to coverage, co-payment in the more American vernacular. A 20% excess is often not understood as well as a 20% co-payment is. Regardless of the cost of the claim, you will be paying a part of it.
- With RegularCare and KiwiCare, the coverage of Psychiatrists is $600 per claim year with the same requirement for being an affiliated provider as Wellbeing Two.
- With the RegularCare option, you also have a similar $400 per annum for prescriptions.
- However, you don't have other modules with this range of cover you can add or remove.
- There is a budget option where an additional $500 excess can be applied to reduce premiums.
- While also increasing your co-payment where the excess applies doesn't impact the area we are discussing here.
The UltraCare Plan:
- Also now the only plan that will cover off pre-existing conditions after three years, has a similar response to WellBeing Two, $750 per annum.
- The difference with this plan is that the Psychiatrist you are seeing does not have to be an affiliated provider. This could be useful in some areas.
- The day to day care of WellBeing One and Two is baked in on this plan, with $100 per visit, double the WellBeing contribution and a similar $600 per year for prescriptions.
- The UltraCare plan does have additional features over the Wellbeing plans with $150 per visit up to $600 per annum for clinical psychologist consults.
So what do you do?
As you can see, the response from medical insurers for this area is widely varying. It definitely is not one size fits all.
However, understating what can be achieved is the first step to putting together an effective risk management solution for you.
When put in context, what are relatively minor costs being covered here for psychological services should not outweigh the significant medical costs that can be incurred with other medical conditions.
This is where a discussion with me is critical to working through the pros and cons of one approach over another.
Being able to operate across all providers in the New Zealand market gives us the apply to assist with getting it right for you.
If in doubt or have questions, please contact us to have a chat.