The Patient Protection and Affordable Care Act (P.L. 111 148) and Modifications by the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), commonly called the Health Care Reform Act, that was signed into law on March 23, 2010, does not really modify health care. However, it does change how health care is covered by insurance in important ways for people who have diabetes, or people who have children or other dependants who have diabetes.
Many people with diabetes have been denied coverage because they had a preexisting condition, diabetes. These preexisting condition exclusions either denied insurance altogether or excluding the preexisting condition from coverage. This meant that individuals would have no insurance for the one condition they knew they would need care for. Congress passed a law that will resolve some of these inequities. Below I describe some of the most important provisions that can affect individuals with diabetes. This is just a short summary and does not contain all the specifics. Please contact your own insurance company or other health management organization to obtain the specifics that apply to you.
If you are a person with a preexisting condition, including diabetes, and are over 22 years of age you will be able to stay under your existing plan if you have one and it covers your health care needs. If you are not covered under your employer’s plan, or your existing plan does not cover your preexisting conditions, or you are not covered under Medicaid, you will be able to obtain health insurance from a state run high risk pool now. Annual out-of-pocket medical costs will be capped at $5,950 for individuals and $11,900 for families.
By 2014, you will be able to obtain health insurance from any health insurance company. The insurance companies will not be allowed to deny coverage because of a preexisting condition such as diabetes. If you make less than four times the poverty threshold, you will be eligible to get subsidies from the government. That means you will pay somewhere between 2 percent and 9.5 percent of your income for insurance, and the government will cover the rest. Health plans will need to cover at least 60 percent of medical costs. Companies will not be allowed to charge more for individuals because of their sex or health status, or charge older people more than three times what they charge for younger people. Insurance companies will also have caps on their profits, they will be required to spend between 80 cents and 85 cents of every premium dollar on health care.
If you are a child or have a child who has diabetes or another preexisting condition, no insurance company will be able to deny coverage because of the preexisting condition. Within 6 months you will be able to obtain health coverage for these children through private insurers or through Medicaid if the family income is less than 133 percent of the poverty amount.
If you are or have a dependant adult child who is less than 26 whose parent has health insurance, this dependant will be able to be covered under their parent’s health insurance by the beginning of next year. The parent will be able to obtain information on how to include these children under their policy in the near future.
If you make less than 133 percent or of the poverty amount, you will be able to have Medicaid cover your health costs if you are younger than 64. There will be new co-pay amounts for name brand and generic drugs. No one will be allowed to intentionally impoverish a spouse through a will or divorce settlement to force the spouse to obtain Medicaid coverage. Medicaid’s reimbursements will be increased to the same level as Medicare, making more doctors willing to accept it.
If you are on Medicare, there are provisions to lessen and eventually eliminate the “doughnut” hole that currently occurs under Part D programs for drug coverage. Medicare will also now cover annual wellness consultations. While there cannot be any cuts in mandatory benefits, there will probably be cuts in discretionary benefits.
For everyone, all annual limits on coverage are removed immediately and lifetime limits will be eliminated by 2014. Also, as a minimum, insurance must cover medical needs for people with disabilities that include rehabilitation and habilitation services, and mental health services. Starting in 2014, everyone needs to be covered under some health insurance program, either a government plan like Medicaid or a private plan. Some lower income individuals will be eligible for financial assistance.
Most individuals must either be covered under an employer’s health insurance plan or buy their own insurance. Most people who refuse to buy into a plan will pay a penalty.
Other provisions in the bill establish 1) the Community First Choice Option to encourage states to provide care through local programs, 2) a Community Living Assistance Services and Supports (CLASS) program, that is a new national long-term care insurance program funded through voluntary payroll deductions, 3) a State Balancing Incentive Program that provides funds to augment Medicaid monies with Federal grants where the state currently spends less than 50 percent of total expenditures for long-term care on services in the home or community to increase their proportion of non-institutionally-based long-term care services, 4) several programs that encourage integrative coordinated care, 5) a program to ensure additional oversight and record keeping for nursing homes, and 6) a program to train a workforce to care for the elderly in nursing homes and at home.
In summary, there will be major changes in our health insurance programs over the next few years. While the provisions are fairly straightforward, the specifics have not been determined yet. As the saying goes, the devil is in the details. No matter what, this program will make it possible for many people with diabetes to afford health insurance and their medical treatment.
Note: This is not legal advice. I'm not your attorney. Some of this information will vary in your state. This provides general information and a start in deciding what to tell your lawyer.