The Patient Protection and Affordable Care Act (H.R. 3590, Public Law 111-148) was signed into law on March 23, 2010. Implementation of this law will be a lengthy process with some provisions effective immediately and others that will not go into effect until 2014.
Two important provision of the insurance market reforms that go into effect immediately. These include prohibition of denying coverage based on pre-existing conditions in children and imposition of lifetime caps is prohibited.
As of 2014 when many permanent provisions go into effect, states must have health insurance exchanges (or alternatives) through which people and some employers may purchase health insurance. In addition, most people will be required to have health insurance unless they are eligible for health care through government programs such as Medicare, Medicaid, Department of Veterans Affairs and military service. There will be refundable tax credits for some people based on income and tax credits for some small businesses that provide health insurance to their employees.
Below is a summary of some of the provisions that have an impact on individuals with disabilities and dates in which they go into effect.
Insurance Market Reforms
1. No Discrimination Based on Pre-Existing Conditions
As of 2014, the law prohibits insurance companies from refusing to insure an individual because of a pre-existing condition. Therefore, an individual could not be refused because of a developmental disability or any condition associated with it, such as a heart defect.
In addition to the prohibition against denying coverage because of a pre-existing condition, insurers will no longer be allowed to charge higher premiums based on a disabling condition, withdraw coverage after someone is injured or acquires a new condition, or impose annual caps on benefits. Most of these provisions go into effect for children in September 2010.
2. Lifetime and Annual Benefits Caps
Lifetime caps on benefits are prohibited immediately. Between now and 2014, the Secretary of Health and Human Services (HHS) may restrict annual caps on benefits. As of 2014, both lifetime and annual caps on benefits are prohibited.
3. Temporary High-Risk Pools
Between now and 2014, many people with pre-existing conditions are eligible to purchase coverage through high risk pools. Unfortunately, to be eligible to purchase this insurance, people must have been without any health coverage for at least six months.
Home & Community-Based Services
1. Community Living Assistance Services and Supports -CLASS
Beginning in 2011, the CLASS provisions, which establish a national voluntary, insurance program, will take effect. In this program, people with functional limitations can receive benefits of not less than an average of $50 per day to pay for services and supports of their choice that help them with activities of daily living. To qualify, people will have had to pay premiums, by means of a voluntary payroll deduction plan, for at least five years. Additionally, they need to have worked for at least three years and earned at least one quarter of credit towards social security.
Individuals do not have to “spend-down” or exhaust their resources to qualify for this program. The Department of Health and Human Services is required to develop an actuarially sound benefit plan so that the program is self-sustaining.
2. Community First Choice Option
This option allows states to provide home and community-based services and supports as the mandatory program for individuals with disabilities with incomes up to 150% of the Federal Poverty Level, who would otherwise require institutional care. To encourage states to choose this option, states that chose to implement this program will receive an additional six percent in the federal government’s share of Medicaid costs (referred to as the Federal Matching Assistance Percentage or FMAP) for five years.
3. Money Follows the Person
Extends the popular Money Follows the Person demonstration grants until September 2016. These grants help state Medicaid programs defray the cost of moving eligible Medicaid recipients who have resided in an in-patient facility for a minimum number of consecutive days into community-based settings.
4. Home and Community Based Services in Medicaid
Makes it easier for state Medicaid programs to offer home and community based services by allowing states to do so by amending their state plan, rather than having to apply for a Medicaid waiver, which can be a lengthy process.
Essential Benefits
For some health insurance plans, including those offered in the exchanges, and individual and small group plans, the law mandates coverage of at least the following essential benefits: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.
HHS has the authority to further define essential benefits consistent with these required elements and is expected to do so. If HHS adds essential benefits, the law requires HHS to take into account the health care needs of people with disabilities and other diverse groups. We will continue to make our voices heard as HHS goes through the process of defining essential benefits.
Additional Important Changes
Substantial Expansion of People Eligible for Medicaid
As of 2014, health care reform expands Medicaid to cover non-elderly, childless adults for the first time and adults with incomes up to 133% of the Federal Poverty Level. It also expands Medicaid to cover children in families with incomes up to 133% of the Federal Poverty level, and it extends Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) mandates to all children on Medicaid including those in managed care. EPSDT services address developmental disabilities and delays. States will receive an increased Federal matching share for the first few years. In 2009, 133% of the Federal Poverty Level for individuals was $14,404 and for families of four was $29,327.
Between now and 2014, states have the option of extending Medicaid coverage to these groups.
In addition, states are required to maintain their current services under Medicaid and have incentives to cover preventive services and immunizations without cost-sharing to adults under Medicaid.
Some changes were made regarding the Medicare 2-year waiting period. Under existing law, people found eligible to receive disability benefits under Social Security Disability Insurance (SSDI) must wait two years before they can receive Medicare benefits. This causes great hardship and often death for individuals who must go without insurance.
Now, some individuals in the two year waiting period may be able to obtain health coverage through the temporary high risk pool or through the health insurance exchanges once they go into effect (which cannot discriminate on the basis of pre-existing conditions) or they may qualify for Medicaid under its extended eligibility standards.
Training of Future Health Practitioners
Requires that medical professionals receive disability awareness training to help reduce the health disparities that exist for people with disabilities. Grants and other incentives are available to develop programs and model curricula to train health professionals and increase the number of health professionals (including dentists) trained to meet the health care needs of individuals with disabilities.
Data Collection and Analysis to Understand and Address Health Disparities
Requires the federal government to collect health survey data from people with disabilities to enable better understanding of the health of people with disabilities compared to other minority groups.
Also requires the government to collect survey data from health care providers in order to learn where people with disabilities receive their care, the number of providers with accessible facilities and equipment, and the number of health care professionals trained in meeting the health care needs of patients with disabilities. Additionally, the law requires the development of recommendations for quality measures to improve the quality of health care for individuals with disabilities.
Post via Sue Hetrick, Director of Public Policy
National Down Syndrome Congress
