Source: Radio New Zealand
New consultations for the assessment of ADHD or ASD would be covered, but not further treatment. (File photo) Unsplash / Naila Conita
Some families of children with ADHD and Autism Spectrum Disorder have been blind-sided by South Cross Health Insurance pulling the plug on funding their treatment.
The insurer said it was not a change in policy but simply a “clarification”.
It has however has taken some specialists by surprise.
Are you affected? Tell us your story: iwitness@rnz.co.nz
In a letter to patients’ families, one paediatrician in Wellington said his practice had received a directive from Southern Cross that its policy was to “exclude coverage for ADHD and ASD, as they classify these conditions as mental health disorders”.
“It is important to note that Dr … does not share this classification.”
New consultations for the assessment of ADHD or ASD would be covered (provided patients had not been previously diagnosed by a doctor), subject to the terms of their policies.
The paediatrician had not responded to RNZ’s request for an interview.
Southern Cross Health Insurance chief sales and marketing officer, Regan Savage, said it wrote to paediatricians in November to “clarify” its existing policy regarding cover for Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD).
“This was not a new directive or change in classification, but confirmation of how our policy needs to be applied.
“We issued the clarification as we had become aware of differing levels of understanding of our policy amongst providers, and our need to ensure our affiliated providers can administer our policy entitlements correctly.”
All consultations prior to a formal diagnosis were funded – but once diagnosis was confirmed, further assessments, consultations and related treatment would not be covered, he said.
“Southern Cross Health Insurance policies generally exclude cover for treatment of mental health conditions and these conditions are classified as mental and neurodevelopmental disorders under internationally recognised classification systems.”
Cover was usually limited to “short-term or unexpected health issues”.
“Conditions like ADHD can involve complex, life-long care such as medication, therapy, and specialist support which creates significant and predictable costs.
“Covering costs like this through insurance would mean much higher premiums for all members, making health insurance less affordable overall.”
Some policies however did fund GPs, nurse and Pharmac-subsidised prescriptions in relation to mental health, Savage said.
Diagnosis ‘just the start’
A Wellington parent – who was not a Southern Cross member herself – said the public system was “already totally under-resourced, which is why people go private”.
“Some families reach crisis point with their kids – they know there’s something wrong, but can’t get into the public system for a diagnosis, which then opens to the door to some level of support and understanding of what’s happening for their kids.
“They can be in survival mode for months before someone will see them for an assessment – there are long waiting lists in both private and public systems, but at least you know you’ll get to the finish line with private.”
Yet getting the diagnosis was often “the very beginning of the journey” for many families, she said.
“For ADHD it can take months and many appointments to get medication right, for ASD I imagine there are a huge amount of secondary issues they need professional support with.”
More ‘funded’ services needed – advocacy group
ADHD New Zealand advocates for increased access to publicly-funded diagnosis and treatment.
Spokesperson Sarah Hogan said some people were fortunate to be able to get a diagnosis through health insurance.
“But health insurance is beyond the reach of many people with ADHD, so an equitable response requires publicly funded diagnosis and treatment.”
Beyond diagnosis and medication, people living with ADHD sometimes had ongoing physical and mental health needs – but unfortunately the public health system did not fund additional services “specifically for ADHD”, she said.
“When people with ADHD experience mental health issues, it can often be unclear how this may be related to their ADHD and this may be different for different people,” she said.
“The public system does not fund mental health services specifically for ADHD, but people with ADHD may access the same publicly funded mental health services that other New Zealanders access. This is not always adequate.”
In a bid to reduce wait times, the Government has signed off on new rules allowing GPs and some nurse practitioners to diagnose ADHD and prescribe medication.
The new regime will take effect from February 1.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand