Will insurance cover ADHD follow-up appointments?

Public plans insure follow-ups with a physician, not at a private clinic

Your provincial health card pays for medication reviews and check-ins with a family physician or psychiatrist, because those are medically necessary physician services. Ontario's description of what OHIP covers lists visits to doctors as insured, and the other provinces Finding Focus serves work the same way. If a family doctor takes over prescribing after your diagnosis, the follow-up visits themselves cost nothing at the point of care, although any documents you ask for may carry a fee.

Follow-ups at a private clinic sit outside that system. A visit with a nurse practitioner or clinician working with Finding Focus is a private service with a set fee, and the provincial plan does not reimburse it. Whether anyone else pays depends entirely on the wording of your extended health plan, which is the subject of the rest of this page. How often those visits happen, and why, is covered at How often do I need follow-up appointments after an ADHD diagnosis?.

Extended health plans reimburse by provider category, and nurse practitioner is the line to look for

An extended health plan pays for a follow-up when the person you saw belongs to a category the plan lists, and the plan sets the per-visit and annual limits for that category. Most plan booklets have a paramedical or mental health section that names the practitioners covered. The categories that matter for ADHD follow-up are set out below, using a publicly posted Manulife plan for Chartered Professional Accountants of Ontario members as one documented example; your own plan will differ.

The pattern in that example is common: social work and psychology are named, nurse practitioners are not, and a virtual care benefit may or may not extend to a specific clinic. Some group plans do list nurse practitioners or cover them under a nursing benefit, which is why the answer to Does private insurance cover a nurse practitioner ADHD assessment? is always to read the booklet. Call the number on your benefits card, name the provider designation, and ask for the per-visit maximum and the annual maximum before you book.

Per-visit fees are easier to claim than a monthly membership

Insurers reimburse itemized services with a date, a provider and a fee, and a flat monthly subscription does not fit that mould. Finding Focus offers ongoing care two ways for adults: an optional membership at $29.99 per month, or $74.99 per check-in with no membership. For youth the figures are $49 per month or $99.99 per check-in. The per-check-in option produces a receipt for a specific visit on a specific date, which is what a claims form asks for. A membership receipt shows a recurring charge and may be treated as a program fee rather than a health service.

• If you plan to claim, ask the plan first whether it reimburses a monthly care membership at all; some do not, whatever the provider's designation.
• If the plan says no to memberships but yes to the provider category, per-check-in billing may be the better fit for you, even if it costs more across a year with frequent visits.
• Keep every receipt regardless. Amounts your plan does not reimburse may still be claimable on your tax return if the provider is a CRA-authorized medical practitioner in your province.

This is a claims-processing point, not a clinical one. The number of follow-ups you need is set by your treatment plan and the guidelines the clinician follows, not by what a plan will reimburse.

Therapy sessions with a Registered Social Worker usually fall under a listed benefit

Follow-ups that take the form of therapy tend to be the easiest to claim, because social work is a category most extended health plans already name. Finding Focus therapy is delivered by a Registered Social Worker (RSW) on the care team, in 50-minute sessions by video or phone from $149 per session, for adults physically located in Ontario. Receipts carry the RSW designation and registration number, which is what the paramedical benefit needs. Cognitive behavioural therapy sessions are usually reimbursed under the social work or mental health line; ADHD coaching is usually not, even from the same practitioner. The details are at therapy fees and insurance.

Two limits apply almost everywhere. The per-visit maximum in the example above is $65 for a subsequent visit, so a $149 session would leave you paying the difference. And annual maximums of ten to fifteen visits, or a dollar cap in the low hundreds to low thousands, are typical of retail and small group plans, so a course of therapy can exhaust the benefit before it ends. If low mood or anxiety is part of why you are in therapy, say so at intake; and if you need help now, call or text 9-8-8, Canada's Suicide Crisis Helpline, or call 911.

Referrals, deadlines and receipt details decide whether a claim is paid

Three administrative rules stop otherwise valid follow-up claims. Manulife's published CoverMe claims information illustrates all three for its personal plans, and group plans have close equivalents.

1. Physician authorization. CoverMe states that your attending physician must authorize services from a psychologist before a claim can be considered. If your plan has a similar rule, get the referral note before the first therapy session, not after.
2. Claim deadline. CoverMe requires all claim information within 12 months of the date you paid. Group plans often set a shorter deadline tied to the end of the benefit year.
3. Receipt contents. The receipt must show the patient's name, the dates of service, a description of the service, the cost of each service, the provider's address and the currency. A booking confirmation or credit card statement is not enough.

For a broader picture of how the initial assessment is treated, including workplace plans, see Does insurance cover an ADHD assessment in Canada? and Does work insurance cover ADHD medication and treatment?. Follow-ups follow the same categories, one visit at a time.