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Navigating the Affordable Care Act

On October 10, 2013 @ 3:13 pm In All Articles,What's New?

[1]

What the New Healthcare Law Means For Allergy & Asthma Patients

The Patient Protection and Affordable Care Act (ACA), passed by Congress and signed into law by President Obama in March 2010, provides new options for health insurance coverage.

What does the law mean to parents, caregivers and patients with allergies and asthma? Many details are still being ironed out through the federal rulemaking process – and the long-term ramifications have yet to be seen – but some major elements of ACA are effective now and others will go into effect on Jan. 1, 2014.

To help clarify and raise awareness of new consumer rights and protections afforded under the new law, Allergy & Asthma Network Mothers of Asthmatics (AANMA) has outlined various scenarios to demonstrate the impact that specific provisions will have on you and your family.

 

Continuing Coverage for Chronic Illness

Scenario Effective Now Under ACA
My allergist has recommended weekly venom immunotherapy during the next 3-5 years to reduce my bee sting reaction. Can my health insurance company drop me if treatment is costly? It’s illegal for health insurance companies to arbitrarily cancel your health insurance due to a chronic illness or “high use” of healthcare.

“High use” protection applies to all health insurance plans, whether you get coverage through your employer or buy it yourself. Your insurance company can cancel your coverage if you put false or incomplete information on your application on purpose, but not if you require expensive care.

 

Free Preventive Care

Scenario Effective Now Under ACA
My insurance does not cover my daughter’s allergy and asthma screenings. Asthma and allergy screenings and tests must be covered under all plans at no cost to you, as long as they are recommended and conducted by a board-certified physician.

The new law focuses on prevention and primary care to help people stay healthy and to manage chronic medical conditions before they become more complex and costly to treat. National guidelines have established that early detection and care for allergies and asthma can lead to a significant reduction in the frequency and severity of symptoms and improved quality of life.

Under ACA, insurance companies must cover preventive care and eliminate cost sharing for services, such as co-payment, co-insurance or deductible. However, if you choose or remain with an insurance plan that has not changed since March 2010, the free preventive care might not apply to you. Check with your insurance carrier.

 

Elimination of Gender and Age Price Inequality

Scenario Effective Now Under ACA
I am a 56-year-old woman with severe allergies. Why does my health insurance cost more than it would for a man the same age or a younger woman? Your health plan cannot charge you more due to your gender, age or health status.

Prior to ACA, women could be charged more for the same health insurance coverage simply because of their gender or age. Through a practice known as “gender rating,” women pay $1 billion more each year in higher premiums than men do for the same health coverage in the individual market.[1] [2]

 

Individual Child Insurance

Scenario Effective Now Under ACA Effective Jan. 1, 2014 Under ACA
My 6-year-old son has chronic and severe asthma. It is cost prohibitive to keep him on our family health insurance plan. Individual plans have either refused to cover him or quoted rates so enormous we couldn’t afford it.

Insurance companies cannot charge a child with chronic illness more than twice the standard rate.

You can purchase health benefits for your children on the individual insurance market without being denied or paying significantly more due to gender or pre-existing conditions.

Child-only health insurance policies make up about 8 out of every 10 policies within the individual insurance market.[2] [2] However, if your child falls within the insurance company’s definition of a high-risk group, such as boys with asthma, it has been a formidable task to find a policy at a reasonable rate.

Beginning Jan. 1, 2014, parents of children with a pre-existing condition cannot be denied insurance or charged more for it, regardless of the type of policy. To bridge the gap between now and then, ACA limits insurance companies from charging more than twice the standard rate for the same type of coverage.

 

State Health Insurance For Adults With Pre-Existing Conditions

Scenario Effective Now Under ACA Effective Jan. 1, 2014 Under ACA
I am a 45-year-old woman with allergies and asthma and no employer-sponsored insurance. I am afraid I’m going to have to go without health insurance until Jan. 1, 2014. Is there anything I can do before then? If you have been without insurance for at least 6 months, you may qualify for your state’s Pre-Existing Condition Insurance Plan (PCIP), temporary programs established by ACA in 2010 to help manage costs and bridge the gap until Jan. 1, 2014, when the new health insurance marketplace takes effect. On Oct. 1, 2013, state exchanges began selling individual policies. These policies cannot charge more for pre-existing conditions.

People with pre-existing conditions have a hard time buying coverage since insurers can deny coverage or charge higher rates based on medical histories. The ACA created a new program – the Pre-Existing Condition Insurance Plan (PCIP) – to make health coverage temporarily available to people with pre-existing conditions.

PCIPs are currently run by either state governments (in 10 states) or by the federal government. To qualify, people must be without health insurance for at least 6 months and either have a pre-existing condition or have been denied coverage as a result of a health condition.[3] [2] (Visit www.pcip.gov [3] for more information.)

As of Jan. 1, 2014, PCIPs will no longer be available.

Individuals whose employers don’t offer insurance will be able to buy into the Health Insurance Marketplace, commonly referred to as Health Exchanges. With a Marketplace application, you can learn if you can get lower costs based on your income, compare your coverage options side by side, and/or enroll. Exchanges will offer a choice of health plans that meet certain benefits and cost standards.

Ending Yearly and Lifetime Limits

Scenario Effective Now Under ACA Effective Jan. 1, 2014 Under ACA
My wife and I have allergies and asthma and purchased a plan with broad coverage. The plan limits how much the insurance company will pay in medical bills annually and over our lifetime. My wife had an anaphylaxis attack and was rushed by ambulance to the ER for treatment. Now our health insurance provider says we have reached our annual cap and we’re going to receive a $10,000 hospital bill. Lifetime caps on essential health benefits are eliminated; annual limits cannot be less than $2 million. The list of essential health benefits includes ambulance and emergency services, hospitalization, prescription drugs, laboratory services and chronic disease management and prevention. All annual and lifetime monetary caps are eliminated.

Lifetime dollar caps are now illegal and annual limits are being phased out. Exceptions: Insurers can still impose other types of limits, such as on doctor visits, prescriptions, or days spent in the hospital. There are no annual dollar limits on essential health benefits, including chronic disease management of allergy and asthma, beginning Jan. 1, 2014.

 

Elimination of Conditional Limits

Scenario Effective Now Under ACA Effective Jan. 1, 2014 Under ACA
I’m a 48-year-old free-lance writer. I have asthma that is well controlled with medication. I recently decided to purchase health insurance that included drug coverage. The only affordable plan I could find had an exclusion period for asthma medications. For the first 12 months of my policy, all of my asthma medication claims were denied. Conditional and chronic limits can no longer apply to children up to age 19.

Insurers may not apply conditional or chronic limits on any health insurance plan.


Your health insurance plan may not cover all care or services related to your allergy and asthma. Depending on the policy and your state’s insurance regulations, an exclusion period can range from 6 to 18 months. Insurance companies sometimes also deny coverage for chronic conditions not expected to show improvement within a certain time – a clause that has been applied to some asthma cases. The ACA eliminates all conditional and chronic conditional limits, effective immediately for children under 19 and Jan. 1, 2014 for adults.

 

Uncharted Territory

ACA is historic and millions of people will have access to healthcare because of it. Seems straightforward, right? Unfortunately, putting any landmark statute of this magnitude into action is anything but straightforward. We are headed into uncharted territory and we’ll all learn the long-term implications of the law together.

It’s important to understand your rights as a consumer. The ACA’s fiscal impact to you – parents, caregivers and patients with allergy and asthma – is as unique as your personal circumstances. However, the law should make healthcare more accessible, and as a result, people with allergy and asthma are more likely to obtain cost-effective primary and specialty care services.

 

– By Kimberly Turner, AANMA director of government affairs



To learn more about ACA, visit www.healthcare.gov [4]. (Spanish language version of the web site is www.CuidadoDeSalud.gov [5].)

Share your scenario! Email us at editor@aanma.org [6].


 

 

 

 

Footnotes

1 National Women’s Law Center Report, March 2012

2 Kaminsky & Associates, Inc., October 2010

3 If you currently have an individual health insurance plan – the kind you buy yourself, not through an employer – your pre-existing conditions may not be covered. However, you can switch to a marketplace plan during the open enrollment period and immediately get coverage for pre-existing conditions.


 

Reviewed by James Sublett, MD, Serena Lowe and Tera Crisalida, PA-C



Article printed from Allergy and Asthma Network Mothers of Asthmatics: http://www.aanma.org

URL to article: http://www.aanma.org/2013/10/navigating-the-affordable-care-act/

URLs in this post:

[1] Image: http://www.aanma.org/wordpress/wp-content/uploads/ACA.jpg

[2] [1]: #_ftn1

[3] www.pcip.gov: http://www.pcip.gov

[4] www.healthcare.gov: http://www.healthcare.gov

[5] www.CuidadoDeSalud.gov: http://www.CuidadoDeSalud.gov

[6] editor@aanma.org: mailto:editor@aanma.org

[7] FDA proposal threatens access to care for asthma and allergy patients: http://www.aanma.org/2012/05/fda-proposal-threatens-access-to-care-for-asthma-and-allergy-patients/

[8] The New Asthma Guidelines: Setting Priorities for Asthma Care: http://www.aanma.org/2009/04/the-new-asthma-guidelines-setting-priorities-for-asthma-care/

[9] Asthma patients shut out from NIH-funded standards of asthma care: http://www.aanma.org/press-room/press-releases/050709-juanita/

[10] The importance of follow-up care: http://www.aanma.org/2011/06/the-importance-of-follow-up-care/

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