The Affordable Care Act ( also known as “Obamacare”) is the most important Federal medical legislation to be enacted since Medicare.
The goal of this Act is to improve healthcare coverage, access and quality to all Americans.
However people with diabetes have benefited with the comprehensive reforms in the act.
We will cover the following topics below
1. The major changes in healthcare that will take place over the period of 10 yrs from the date the Act as signed in 2010
2. Who will need to purchase insurance on the the web-based exchange
3. The cost to individuals and the rebates they can expect
4. The rules and regulations for purchasing insurance
5. The different insurance plans that are available
6. The States that are participating
We have tried to give you a brief overview of the Affordable Care act that is of importance to practitioners who care for diabetics by discussing both the pros and cons of the program as they relate to diabetes care.
The Affordable Care Act ( ACA) was passed by Congress and signed into law on March 23, 2010. Some parts of it became law in 2014 and other parts will be phased in by 2020.
It is the most substantial change in US healthcare since the passage of Medicare in 1965.
One of the main reasons for this bill was to provide health insurance to approximately 40 million Americans who were not covered by some type of health insurance. It was also designed to overcome specific deficiencies that existed in the healthcare system.
Not all individuals in the United States will be covered by ACA medical insurance.
Individuals not covered include (1) illegal immigrants (2) U.S. citizens who are eligible for Medicaid but who are not enrolled in this program (3) U.S. citizens not otherwise covered but who choose to pay the annual penalty instead of purchasing insurance.(4) U.S. citizens whose insurance premiums would cost more than 8% of their household income are exempt from paying the annual penalty. (5) citizens who live in states that opt out of the Medicaid expansion and who qualify for neither Medicaid coverage nor are subsidized through these states’ new insurance exchanges are not covered.
Overall, the drafters of the ACA believed that increasing coverage would not only improve the quality of life for many citizens but would also reduce both medical bankruptcies (the most common cause of bankruptcies in America) and job lock (the unwillingness to leave one job to take another because of fear of losing medical insurance).
State-based insurance exchanges are set up by ACA. These exchanges are online market places administered by either the states or the federal government at which individuals and small businesses may compare and purchase private insurance plans that have been preapproved. These Web sites are regulated, and the plans are comparable either directly or by contacting a call-in center. Specific enrollment periods will be set to discourage individuals from delaying coverage until they become ill. Only approved insurance plans that meet specified standards will be allowed to be sold on the exchanges.
The approved plans must comply with the following conditions.
1. There is a ban on the ability to drop policyholders if they become sick.
2. There is also a ban on price discrimination on the basis of preexisting conditions or gender.
3.Children and dependents must be permitted to remain on their parents’ insurance plans until their 26th birthday.
4. Insurers cannot impose annual or lifetime caps coverage on essential benefits
How the ACA is Beneficial to Diabetes Patients
The ACA helps diabetes patients in the following manner
Nonexclusion of preexisting conditions
As per the ACA, health insurance coverage cannot be denied to patients with preexisting conditions . All people with type 1 diabetes, and many with type 2 diabetes, would probably be excluded from purchasing healthcare coverage on the individual marketplace because of preexisting disease exclusions. The U.S. Government has asserted that preexisting disease exclusions likely affect between 50 and 129 million adults (i.e., up to 50% of adults). Many people are affected by preexisting disease exclusions even if they currently possess health insurance from their employer because of “job lock.”
Job lock is the phenomenon that occurs when workers are reluctant to leave their current occupation in favor of one that they might prefer because of a fear of being unable to obtain (or afford) health insurance once they leave the protection of their existing group health coverage.
Because the ACA will eliminate preexisting disease exclusions and will result in widely available healthcare coverage (and freedom from job lock) for people with diabetes, it is probable that this health disparity will be significantly reduced by the ACA.
No limit on lifetime/annual benefits
The ACA does not allow health plans from putting a lifetime dollar limit on most benefits. Effective September 23, 2010, a group health plan may not establish any lifetime dollar limits on the value of “Essential Health Benefits” for any individual under the group health plan. However, a group health plan may impose lifetime limits on the dollar value of specifically covered benefits that are not “essential health benefits” to the extent that those limits are not otherwise prohibited under federal or state law.
Essential health care benefits include, but are not limited to, doctor office visits, hospital care, and prescriptions. Before the ACA, many health plans could limit how much they would spend to cover health benefits each year (“annual dollar limit”). Many health plans could also set a “lifetime dollar limit” on how much they would spend to cover health benefits for the entire time that a person was enrolled in a plan. Anyone who incurred healthcare costs higher than these limits would have to pay the amount that was over the limit.
A health plan cannot limit the total amount it will spend to cover benefits during the entire time an individual is enrolled in the plan. This new law applies to all employer-based group health plans (“group coverage”) and all individual insurance coverage purchased for an individual and/or his or her family. As such, the ACA phases out annual dollar limits a health plan places on most of the benefits. .
Children and young people to stay on parents’ plans
Most young people can stay on their parents’ insurance plan until the age of 26 years, even if they’re married, financially independent, and no longer live with their parents. Young adults who are covered by their employers can choose that plan or remain with their parents’ plan if they prefer. If the parents don’t claim the young adult as a dependent on their tax return and the young adult’s own income is below 400% of the federal poverty level, he or she could be eligible for premium tax credits on the exchange. But, if the parents do claim the young adult as a dependent, his or her eligibility for subsidies will be based on the family’s income, not just the young adult’s income. In addition, if the young adult plans to become pregnant while on her parents’ plan, she should check to make sure maternity benefits are covered. Although most group plans must provide maternity coverage for employees and their spouses by law, children aren’t protected by this law, and employers don’t always provide coverage.
Free preventive services
The ACA provides designated preventive services at no cost to the enrollee as shown in Table 4,
Although certain of these preventive maneuvers can be interpreted as specifically benefitting individuals with diabetes (such as pneumococcal and influenza vaccines, depression screening, preventive tooth care for children, and prepregnancy contraception), most of these items are not diabetes specific. Although free preventive services represent a boon for Americans in general, people with diabetes are especially poised to benefit. Much of this benefit is derived from improved coverage of screening services to increase case detection rates and to identify diabetes (or prediabetes) at a stage when it is easier to treat and more amendable to lifestyle change. According to the Centers for Disease Control and Prevention, the ACA covers services that include type 2 diabetes screening, diet counseling, and blood pressure screening. In addition, Medicare also covers diabetes screening tests to identify beneficiaries with diabetes or those who are at high risk of developing diabetes (i.e., persons with prediabetes). Other Medicare preventive benefits such as diabetes self-management training and medical nutrition therapy are offered in an attempt to support enrollees in self-care and in making lifestyle changes to prevent or minimize development of the comorbidities and complications of diabetes. Medicare Advantage plans (a type of Medicare health plan offered by a private company that contracts with Medicare to provide the insuree with Part A and Part B benefits) have additionally identified 36 Special Needs Plans focused on chronic disease care. These plans are being offered for Medicare patients with diabetes, with benefits that include (1) health education for all beneficiaries on ways to prevent diabetes, (2) extra self-care skills training for those with diabetes, and (3) focused disease management programs that provide care coordination and in-home monitoring to prevent development of comorbidities and complications of diabetes.23
Plan types, including coverage for catastrophic medical expenses
As anticipated, there are several plans available from which the diabetes patient may choose (Table 5). The “metallic” plans (bronze, silver, gold, and platinum) reflect an effort to share costs between insurer and insured. For people below 400% of the federal poverty level, discounts will be available. As of 2013, for the lower 48 states and the District of Columbia, the income level was $45,960 for singles, $62,040 for a married couple with no children, and $94,200 for a family of four. These plans do not include the catastrophic coverage option. Everyone’s out-of-pocket maximums will be the same (regardless of the plan they choose) unless each state decides to change the limits for higher plans (such as California has done with Platinum plans). As it now stands, regardless of the plan that is chosen, the maximum out-of-pocket cost for healthcare, aside from insurance premiums, will be the federal limits for high-deductible healthcare plans. In 2014, that limit was $6,350 for singles and $12,700 for families. Analysts expect young adults to gravitate toward the bronze and catastrophic plans, which are the lowest-cost options. Both the bronze and the catastrophic plans cover basic preventative health services, including cholesterol tests, immunizations, and screenings for depression and alcoholism. Both also cover, to varying degrees, all categories of essential health services.