The Affordable Care Act (ACA) expanded health coverage for uninsured Americans, while also taking steps to control health costs and improve the healthcare delivery system. But many are still confused about what the ACA means to them.
Before the ACA, millions of people went without health insurance because they couldn’t afford it. Now with the ACA in place, there will be expanded options for people, especially those who were previously uninsured.
Here’s a primer:
The Individual Mandate
The individual mandate is the ACA requirement that most people purchase comprehensive health insurance coverage starting in 2014. Those who opt out will have to pay an annual penalty the greater of: $95 or 1% of an individual’s annual income in 2014, $325 or 2% of an individual’s annual income in 2015, or $695 or 2.5% of an individual’s annual income in 2016 and thereafter.
Several states and other petitioners challenged the mandate, arguing that it is unconstitutional for Congress to pass a law requiring individuals to purchase health insurance. But in a 5–4 Supreme Court decision on June 28, the court upheld the individual mandate, stating that it was within Congress’ constitutional authority to set and collect taxes. If you choose not to purchase a policy, you have to pay the penalty, which the court ruled is the equivalent of a tax.
Implications for People with Bleeding Disorders
If you’re uninsured: Starting in 2014, you have to get health insurance coverage if you were not exempted. You may be eligible for Medicaid or a private plan in a health insurance exchange, with a subsidy to help pay for premiums and out-of-pocket costs. But if you choose not to get health insurance, you may have to pay the penalty when you file your taxes the next year.
If you have employer-sponsored health insurance, you can keep your plan. A very small number of employers offer coverage that doesn’t meet minimum requirements, which leaves workers at risk for unpaid or unaffordable healthcare bills. If those employers don’t improve their coverage, employees can buy other coverage through health insurance exchanges. Financial help will be available to those who qualify.
If you have an individual policy, participate in a high-risk pool or are self-employed, you can get coverage through health insurance exchanges starting in 2014.
Medicaid Expansion
The ACA includes a requirement for states to expand Medicaid eligibility to people under 65 with annual incomes below 133% of the federal poverty level ($14,856 for an individual or $30,657 for a family of four in 2012) by January 1, 2014. Although the Supreme Court ruled the expansion to be constitutional, it also ruled that the federal government cannot penalize states refusing to expand their Medicaid programs.
Other Key ACA Provisions
Many other provisions in the ACA are important for people with bleeding disorders, including:
No more lifetime limits (caps) and restrictions on annual limits: Because of the high cost of clotting factor, people with hemophilia were prone to reaching maximum lifetime caps set by insurance companies. When a person reached that limit, the plan stopped paying for care. The ACA banned lifetime dollar limits on coverage for “essential health benefits.” This provision applies to all plans, effective for the plan year beginning on or after September 23, 2010. There are also restrictions on annual dollar limits for essential benefits for plan years prior to January 1, 2014, when limits will be prohibited. But the law does not prevent insurers from imposing lifetime and annual limits on benefits not considered “essential health benefits.”
Expanded coverage for pre-existing conditions: Health insurance companies can no longer deny coverage to children and teens under age 19 if they have a pre-existing medical condition. In 2014, that ban will also extend to adults. In addition, plans will be prohibited from charging people more for health insurance because they have pre-existing conditions.
Until then, if you are an adult with a bleeding disorder—or another pre-existing medical condition—and have been uninsured for six months or more, the Pre-existing Condition Insurance Plan (PCIP) may work for you. PCIP will be available until 2014, when it will be replaced by health insurance exchanges. (See “Plan in Progress,” HemAware, Summer 2012, p. 12.)
Expanded dependent coverage: Young adults are least likely to have insurance. Under the ACA, parents can now keep their adult children on their health insurance plans until age 26.
Protection from cancellations: Insurance companies had been able to drop people from coverage for minor errors made on applications. Because of the ACA, insurers are no longer allowed to cancel your policy without sufficient cause.
No more denials: Starting in 2014, health insurers are required to issue an individual policy to any eligible applicant regardless of his or her health status. Further, they cannot consider health status when determining cost of premiums.
The National Hemophilia Foundation is tracking the progress of the ACA. Stay tuned for future updates.
Ruthlyn Noel, MPA, is senior manager of public policy at NHF.