The controversy over the new health care law passed by Congress and signed into law by President Obama in March of 2010 raised many valid questions:
- Was it too much “big government?”
- Can taxpayers afford it?
- Would a bipartisan bill have been better?
- Should reform have been incremental?
- Will the quality of health care break down and lead to rationing?
- Was it the right time to pass such a costly bill (estimated at $940 Billion over 10 years)?
- Should President Obama have focused his time and energy on getting our economy back on track instead of on health care reform?
Despite these important questions, one thing is clear:
The Affordable Care Act of 2010 is the most important health care law for people with disabilities since the passage of Medicare and Medicaid in the 1960s.
One quick “trivial pursuit” type item before we get into the important new benefits of the law: What people refer to as the “new health care law” or the “Affordable Care Act” is actually two laws: The Patient Protection and Affordable Care Act (PPACA) signed by President Obama on March 23, 2010 and the Health Care and Education Reconciliation Act President Obama signed into law on March 30, 2010.
Here Are The Top Ten Ways The Affordable Care Act Helps Individuals With Disabilities:
1. No more lifetime limits on coverage (effective September 23, 2010 applying to all plans). Now parents who have a child with a chronic illness that requires expensive on-going medical treatment will never have to hear the news: “Your child has reached his or her lifetime cap on coverage.” Such terrifying news often meant no treatment for the child or bankruptcy for the parents. In addition, the new law regulates annual insurance limits starting in September, 2010 and prohibits annual limits by 2014.
2. No more denying coverage due to a pre-existing condition for children under the age of 19 (effective September 23, 2010 and applying to all employer plans and new plans in the individual market, and for adults effective January, 2014). The days of being denied health insurance due to a pre-existing condition or having insurance coverage subject to exclusions for treating pre-existing condition are a relic of the past for children covered under employer plans and new plans. For adults who are cannot get insurance coverage due to a pre-existing condition, beginning in June, 2010 there will be access to insurance through a temporary subsidized high-risk pool which will be taken over by the health care Exchanges in 2014. People under age 65 who have been uninsured for six months are eligible for this coverage. (Note that these Exchanges are discussed below in the section called “Exchanges Are The New Architecture Of Our Health Care System”). By 2014, no more denying coverage due to a pre-existing condition will apply to all people.
3. Young people up to age 26 can remain on their parent’s health insurance policy provided the child is not eligible for their own employer-sponsored coverage (effective September 23, 2010 and applies to all new group health plans and plans in the individual market). This new provision will help young adults receive medical treatment at a critical time in their lives – as they enter the workforce. Such timely medical intervention can change the course of a life. This provision is particularly welcome news for parents who have a son or daughter with a bipolar disorder, depression, or schizophrenia whose symptoms often appear or worsen at this “becoming an adult” age. In the past, many individuals due to their disability worked in menial jobs without health benefits. The U.S. Department of Labor says about 30 percent of young adults have been uninsured. If the individual did not qualify for Medicaid, on-going medical treatment often wasn’t available.
4. No more dropping people from coverage when they get sick (effective September 23, 2010 and applies to all new and existing plans). Have you ever worried, “What if the insurance company drops coverage when my son or daughter needs expensive medical treatment?” Sometimes health insurance companies to avoid paying an individual’s high-cost of treatment would try to cancel (called a policy rescission) the individual’s health care coverage. The health insurance company might review the original insurance application looking for factual discrepancies or omissions as a basis to rescind the coverage. Bottom line: no more rescissions.
5. Free coverage for preventive health services (effective September 23, 2010 and applies to all new group health plans and in the individual market). Beginning September 2010, the law requires new group health plans and individual plans to cover for free (no co-payments or deductibles) Level A or B preventive services (strongly recommended or recommended by the US Preventive Services Task Force). In addition, if your son or daughter is on Medicare, beginning in 2011, they can get free preventive care for many services such as colorectal cancer screening and mammograms and also a free annual physical to develop and update their personal prevention plan based on their current health needs. Annual personal prevention plans to combat early on such disorders as diabetes will save lives and costly acute care treatment.
6. Guaranteed coverage for “essential benefits” for people who purchase through an Exchange by 2014. All new “qualified health plans” will be required to include a minimum group of “essential benefits” to be defined by the Department of Health and Human Resources. These benefits must be at least equal to benefits offered in typical employer plans. Essential benefits will include:
- Hospitalization
- Laboratory Services
- Emergency Services
- Preventive and wellness services
- Pediatric services (including oral and vision)
- Prescription Drugs
- Ambulatory Services
- Maternity and newborn services
- Mental Health and Substance Use Disorder Services (including behavioral health treatments)
- Rehabilitative and habilitative services and devices
Nothing prevents plan from offering a more extensive array of benefits. (Note: For individuals under age 30, plans that only offer catastrophic coverage will be permitted.)
7. More low-income individuals will qualify for Medicaid. All individuals under age 65 with incomes at or below 133 percent of the Federal Poverty Level (FPL) will qualify for Medicaid. (Note: In 2010, the Federal Poverty Level for a family of 4 is $29,400 and $14,400 for an individual.) All states must adopt this expanded coverage by January 1, 2014 and states can begin extending coverage as early as April 1, 2010.
For the first time, individuals who qualify for Medicaid because their incomes are below 133 percent of the Federal Poverty Level will not have to meet other eligibility criteria such as receiving Supplemental Security Income (SSI).
This loosening of eligibility standards is significant because in the past many low-income people were not entitled to Medicaid coverage either because they did not have dependent children or they didn’t qualify for Supplemental Security Income. These individuals “fell between the cracks” of our health care network. Low-income adults without dependent children account for about a third of all the uninsured.
Note that these newly eligible individuals will receive more restricted Medicaid benefits than those on traditional Medicaid. They will get what’s called the “bench mark plan” based on coverage under the SCHIP program (see number 9 below). Benchmark plans for newly eligible’s must offer the essential benefits discussed in number 6 above, but the benefits will be more limited. (Note that many individuals will be exempted from the limits of the benchmark coverage.)
8. Filling gaps in mental health parity laws. The word “parity” comes from the Latin root “par” which means equal. Traditionally, mental health benefits have been subpar as compared to coverage for “physical” conditions. Many insurance companies have restricted the number of therapist visits, assigned higher deductibles or co-pays for mental health treatment, or even refused to cover mental health treatment altogether.
The first major step forward toward mental health parity was in 2008 when the Mental Health Parity and Addiction Equity Act was passed as part of the economic stimulus bill. Essentially, the 2008 bill required health plans that cover 50 or more employees and that offer both medical and mental health benefits must provide mental health benefits that are no more restrictive than the medical and surgical benefits. In other words, mental health benefits must be treated like medical and surgical benefits – same deductibles, co-pays, number of visits, and so forth.
The 2008 law still had some major holes in it. For example, the 2008 law did not apply to small employers (50 or fewer employees) who offered group health plans. And the law also did not apply to insurance plans that offered no mental health or substance abuse benefits. The law only applied to insurance plans that offered both mental health or substance abuse benefits and the medical and surgical benefits.
The second major step toward mental health parity came under section 1302(b) of the new Affordable Care Act of 2010. This provision made mental health coverage an “essential health benefit” (discussed in number 6 above) that all new “qualified health plans” will be required to include. Beginning in 2014, insurance companies are required to provide mental health coverage and it must be equal to the coverage of any other medical condition. In addition, various psychotropic medications are required to be on the list of prescription drugs the insurance plan offers (sometimes called the plan’s drug “formulary”). Note also that maternity and newborn care that traditionally often required additional costs are now an “essential benefit” that must be covered as part of basic care.
9. The State Children’s Health Insurance Program (SCHIP) is extended. SCHIP, or more commonly known as the CHIP program, is a federal program that provides matching funds to states for health insurance for children in low-income families whose incomes are too high to qualify for Medicaid. The new Act requires states to maintain CHIP until at least 2019 with funding through September 30, 2015. In addition, the new Act forbids states from making the eligibility standards for CHIP more restrictive.
10. And much more. There are many other reforms, such as:
- Waiting periods to enroll in group health insurance plans cannot be longer than 90 days (effective 2014).
- The Act establishes an Office of Coordination for Dual Eligible Beneficiaries to help individuals who receive both Medicare and Medicaid coordinate their benefits so gaps in Medicare coverage will be covered properly.
- The law limits out-of-pocket costs and deductibles on plans sold in the small group market. Out-of-pocket costs cannot exceed the limits for Health Savings Accounts in 2014 (currently $5,950 for single policies and $11,900 for family policies). Deductibles cannot exceed $2,000 for an individual or $4,000 for a family.
- Increased funding for community health centers.
- If a Medicare beneficiary enters the Part D “donut hole” in 2010, they will receive a one-time, $250 rebate check if they are not already receiving Medicare Extra Help.
- In 2011, if the Medicare beneficiary reaches the coverage gap, they will receive a 50% discount when buying Part D-covered brand-name prescription drugs.
- Certain drugs, like the benzodiazepines that are useful in treating disorders such as anxiety, insomnia, seizures, will be covered for the Medicaid federal match beginning in 2014.
Exchanges Are The New “Architecture” Of Our Health Care System
In general, the more people in a group the lower the premiums because a greater number of people are helping to pay for those who are sick. That’s why group insurance is generally cheaper than individual insurance. This basic insurance concept is called risk sharing.
The new Affordable Care Act utilizes risk sharing by setting up what’s called “American Health Benefits Exchanges.” These Exchanges are a federally regulated market place where individuals and small business owners can buy health insurance on a state-established website. When buying health insurance on an Exchange, the individual buyer can purchase one of a variety of possible health insurance plans such as PPOs or HMOs administered by private insurance companies. The policy makers intend that people can comparison shop on these Exchanges for competitively priced standardized health packages.
These Exchanges are to be established by January 1, 2014. Larger employers, including state and local governments, at each state’s option will be able to purchase insurance through the Exchanges beginning in 2017. Individuals and employers don’t have to purchase their health insurance through the Exchanges.
Starting in 2014, all citizens and legal residents (other than some people who will be exempt based on hardship, religion, or Native Americans) will be required to have health insurance obtained through their employer, individually, from an Exchange, or through Medicare or Medicaid. Individuals who do not buy insurance will be fined. This individual mandate requiring individuals to buy health insurance is controversial and will be contested in the courts.
Finally, it should be noted again that some of the benefits take effect within the first 6 months of passage of the Act (September 23, 2010) yet the full array of benefits will not be available until 2014.
Copyright © 2010 by L. Mark Russell, All Rights Reserved
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Attorney L. Mark Russell helps parents with a son or daughter with a disability who are worried what will happen to their child after they die. To learn how to give your child a safe future go to www.LMARKRUSSELL.com. Note to all disability organizations: You may use this article for your website or newsletter provided that you use it in its entirety, including this paragraph at the bottom in full. If you use it or have any questions, please email me at LMARKRUSSELL@comcast.net. Thanks!
For information about attorney Russell’s book, Planning For The Future: Providing a Meaningful Life For Your Child With a Disability After Your Death, go to www.LMARKRUSSELL.com/bookinfo.htm.