Need to Know: The Affordable Care Act

Obamacare Ahead Disabled SignThere has been a tremendous amount of information distributed about Obamacare, which has caused considerable angst among people who may be eligible. We will try to put some of the myths and misconceptions to rest in the hope that you find some of the answers you seek about such an important topic.

If you presently have health insurance — either public or private — and that coverage will be in place in 2014 AND it meets minimum coverage requirements, then there’s nothing you have to do to comply with the Patient Protection and Affordable Care Act (ACA). You’ll be able to keep your insurance, uninterrupted.

That’s because the ACA, also known as Obamacare, doesn’t — and isn’t intended to — replace private health insurance. Instead, the act is about expanding the existing health insurance net to include as many people as possible. It aims to do this by expanding public and private insurance coverage, and reducing the costs of health care for individuals and the government. It provides a number of mechanisms — including mandates, subsidies and insurance marketplaces — to increase coverage and affordability.

If you do not currently have health insurance, then it’s highly recommended that you shop at healthcare.gov to find one that’s best for you. As you explore this site, you’ll find that some plans available through the healthcare market are very affordable, but they only offer minimum coverage. So a bronze plan will cover 60 percent of costs, a silver plan 70 percent, a gold plan 80 percent and a platinum plan 90 percent.

Your access to wheelchairs and related medical equipment, assistive technologies, prescription drugs and medical supplies is highly dependent upon which health insurance carrier and which health insurance plan you choose. Pay close attention to what is covered under “Rehabilitative and Habilitative Devices and Services” under each plan and what medical equipment, prescription drugs and medical supplies are available. It is very possible that a platinum plan (the highest level) is actually cheaper than the bronze plan (the entry level), when you take into account the purchase of a wheelchair and/or medical supplies that you use regularly.

The Basics

  • Everyone must have insurance by March 31, or risk paying a fine. If you are already on Medicare, Medicaid or any other government-funded health care, nothing will change for you. If you have no insurance, or if you are self-employed and paying a whole lot for insurance, you are encouraged to log onto the health care exchange at www.healthcare.gov. Although this website was plagued with problems when it first went live in October, most now report they are able to log on, compare plans, and buy one that works for them. And, thanks to tax subsidies that are immediately applied, most people are reporting these plans are significantly cheaper than what had been available to them in the past.
  • Pre-existing clauses are gone — no longer can any insurance company turn a potential customer down because of a spinal cord injury/disease. Also, since everyone must buy into the system or pay a fine, there will be enough healthy people in the system to offset costs of those whose disabilities require more care.

    This reform alone will dramatically expand employment opportunities for people with SCI/D. People with SCI are no longer tied to whichever insurance carrier was in place at the time of their injuries or the onset of our spinal cord disorders, and many will no longer be forced to remain on SSI or SSDI for fear of losing health benefits. In short, the opportunity to find a job, or move from one employer to the next is now easier for people who have the desire and capacity to work.

  • Health insurers can no longer limit or deny benefits to children under 19 due to a pre-existing condition. That’s right, insurance companies were previously able to deny coverage to the children of otherwise insured parents, because of a congenital SCI/D.
  • If a plan covers children, then individuals under age 26 can be included on their parents’ plan. In many cases this is true even if they’re married, not living with their parents, attending school, not financially dependent on their parents, and eligible to enroll in their employer’s plan. It’s no secret we need as many young, healthy people enrolled in health insurance as possible, and this is one way to make that happen.
  • Lifetime caps on coverage for most benefits end. Let’s face it, we’re expensive and many of us reach that $1 million lifetime cap pretty quickly. Additionally, annual dollar limits on coverage will be phased out by 2014.
  • Your insurance carrier can no longer arbitrarily withdraw insurance coverage due to mistakes on insurance applications. This was a frequent occurrence for people with SCI/D, or a history of SCI/D, if they didn’t fully disclose their medical history. Considering how involved many of our disabilities are, these types of mistakes were common. Now we don’t have to worry about losing our health insurance because of an oversight.
  • Insurance companies must now publicly justify any unreasonable increases in premiums. In the past, insurance companies could encourage people to “voluntarily” dump their coverage by making the plan unaffordable.
  • Also, insurance companies must now spend at least 80 percent of premium dollars on actual health care and if they don’t, they must issue a rebate. This is one way to try to keep them honest.
  • Changes to Medicare’s prescription drug coverage will reduce the out-of pocket cost impacts of the “doughnut hole” gap. Some of this has already begun happening, as subsidies to help pay for generic drugs were put in place in 2011. This year, more subsidies will be phased in to help pay for brand-name drugs. By 2020, the gap will shrink from 100 percent to 25 percent.
  • If you currently have coverage through the federal Pre-Existing Condition Insurance Plan (PCIP), be aware that this plan will end Dec. 31, 2013. You must enroll in a new health plan by Dec. 15, 2013 to ensure pre-existing condition coverage that starts Jan. 1, 2014. PCIP was a temporary program put in place to provide immediate relief for people who could not otherwise obtain health insurance, but now that the exchange is up and running, PCIP is being phased out.

The Affordable Care Act and Medicare

People who are already on Medicare or Medicaid do not need to apply for the health care exchanges since they are already covered by insurance. This isn’t exactly good news for everyone, as Sandra Lambert discovered. Lambert is 61, on SSDI for post-polio, and would love to purchase Medi-Gap insurance, but can’t because she uses a wheelchair.

“Nothing has changed for me,” says Lambert, a writer from Gainesville, Fla. But no one could — or would — tell her that officially until the new law rolled out. “I’ve been putting off some medical procedures and getting a new wheelchair hoping that I’d be eligible, and nothing has changed at all.”

In Florida, a person under the age of 65 can purchase Medi-Gap, but not if the person uses a wheelchair. Lambert says Aetna has a plan she could purchase, “But it’s $3,000-$4,000 a year, so basically it’s not real,” she says. “It makes me mad. It’s a terrible thing.”

So Medi-Gap hasn’t changed, but here are a few ways the Affordable Care Act does impact Medicare and DME:

  • There is a 2.3 percent excise tax on medical devices, including wheelchairs. The government is coy about this, saying, essentially, “Well, it’s a tax on the manufacturer, not a tax on the consumer,” but increased costs on manufacturers tend to be passed on to the end user.
  • People on Medicare no longer have an option to buy equipment, but instead must rent it.
  • Competitive bidding for DME is written into the law, and that is expected to dramatically decrease the number of suppliers. This could seriously curtail the ability of people to choose who they want to do business with, and limit them to the options offered by a government-appointed supplier.

“In Medicare’s world, it seems like competitive bidding is working,” says Ann Eubank, vice president of community initiatives at United Spinal Association and the force behind UsersFirst. “But that’s because people don’t know what’s going to happen until they order their next CPAP machine or wheelchair or repair.” They might learn they can’t use the same supplier, or the new supplier is so far away from where they live that they’re stranded without their wheels for far too long. And, on top of it, they might not realize that Medicare’s to blame for changing how people buy equipment and get it serviced. “People don’t know the lingo or who to complain to,” says Eubank. “So I say whatever sucks about your wheelchair or supplier, write it down and let us know.”

— Josie Byzek

To Learn More

Quick Links Via Healthcare.gov

The Health Insurance Marketplace, Affordable Care Act can be found at Healthcare.gov and this is the site where you can shop for insurance. It’s an easy process and people are encouraged to explore before they make a final purchase. Following are some links within Healthcare.gov that provide useful additional information:

No computer? No problem. You may call the Health Insurance Marketplace at 800.318.2596.

How Does It Work?

Enrollment for plans purchased through the healthcare marketplace began Oct. 1 and runs through March 31, 2014, but coverage begins in every state on Jan. 1, 2014. How the program is run may depend upon where you live, as states can choose one of three options:

  • build either a fully state-based marketplace
  • enter into a state-federal partnership marketplace
  • or default into a federally-facilitated marketplace

The latter two options, which involve the federal health insurance marketplace, have been the focus of the majority of the news reports.

The Affordable Care Act directs the Secretary of Health and Human Services to establish and operate a federally-facilitated marketplace in any state that is not able or willing to establish a state-based marketplace. States entering into a state-federal partnership marketplace may administer plan management functions, inperson consumer assistance functions, or both, and HHS will perform the remaining marketplace functions.