What Has Changed

Patient Rights and Protections

The ACA created many rights and protections for health insurance consumers. Some of these rights were already granted to residents of Arizona through state law, but those rights are now federally protected for everyone in the country. Other rights were brand new under the ACA.

Limits on Insurance Companies

One of the most important rights under the ACA is that it is illegal for insurance companies to deny you coverage because of a pre-existing condition. In the past you could be turned down because of a disability, a previous illness, a mental health diagnosis, or any number of other pre-existing conditions. Now insurance companies have to offer plans to everyone.

Also, insurance companies cannot drop your coverage when you get sick. Before the ACA, this was happening to thousands of Americans each year. Insurance companies are not allowed to put annual or lifetime limits on your essential benefits, which include things like hospital stays, prescription drugs, and doctor’s visits. This means that they cannot stop paying for your care because they decide it costs too much.

Insurance companies can’t charge higher rates because of health, gender, or other factors. Higher premiums are allowed based on age (but limited to no more than three times the amount charged for young people), geography, family size, and tobacco use. Also, children can stay on (or be added to) their parents’ insurance policies until they turn 26, if they can’t get insurance through a job of their own.

If your insurance company makes a decision about your care that you disagree with, including denying a claim, you have the right to appeal the decision, both with the insurance company and with an independent agency.

Also, insurance companies are required to spend at least 80% of all the money they get from premium payments on health care services and quality improvement. If insurance companies don’t meet these percentages because their costs or profits are too high, they have to give money back to their customers.

Preventive Health Coverage

Insurance companies now have to cover certain preventive services, like cancer and diabetes screenings. Insurance companies are required to offer these services free to the patient - without deductible, coinsurance, or copayment charges.

The law also ensures that many preventive health services for children are free, including well-baby and well-child visits up to age 21 and many vaccines.

People with Disabilities

There are many protections and rights in the ACA that affect people with disabilities. Protections such as the ban on rejecting people’s insurance applications because of a pre-existing condition make it easier for people with disabilities to get insurance.

There are also some parts of the law that directly address disability issues in health care. The Access Board is a group that develops accessibility standards to meet the requirements of the Americans with Disabilities Act (ADA) and other laws. The ACA asked the Access Board to come up with new accessibility standards for medical equipment. The standards are supposed to make it as easy as possible for people with disabilities to use medical equipment. For more information and updates, visit the Access Board’s website.

AHCCCS

Expanded AHCCCS

As mentioned earlier, if you were on AHCCCS before the ACA, you are able to keep your coverage.

However, there were some changes that expanded AHCCCS coverage to people who weren’t able to get AHCCCS coverage before. It covers more low-income people, including adults without children, and adults without a disability. People with incomes up to 138% of the Federal Poverty Level (about $16,753 for an individual or $34,638 for a family of four) are able to get AHCCCS. The expansion also got rid of asset limits for people in the new eligibility group.

For more information on AHCCCS, read the DB101 article on AHCCCS.

Medicare

As mentioned before, it is important to know that if you were already on Medicare (Original Medicare or Medicare Advantage) before the ACA, your coverage and benefits did not change. New enrollees to Medicare are able to get the same benefits as people already on Medicare. However, there have been a few changes to Medicare.

Closing the Donut Hole

In the past, Medicare Part D has had a gap in prescription drug coverage called the “donut hole.” Under Medicare Part D, when a person’s prescription drug costs reach a certain amount ($3,820), Medicare stops paying for any of their prescription drug costs. The person has to pay for their drugs out-of-pocket, until they reach the maximum out-of-pocket amount ($5,100). Once they reach this maximum, they are out of the donut hole and Medicare starts to help cover the costs again. Before the ACA, a person had to pay for 100% of their prescription drug costs while in the donut hole.

Since the ACA, this has changed. Each year, people on Medicare who fall within the donut hole get a discount on their prescription drugs, to help cover their out-of-pocket costs while in the donut hole. The discount gets larger each year. In 2019 the discount is 75% for brand name prescriptions and 63% for generic drugs. The full cost of brand name drugs (rather than the discounted amount) will still count towards the person’s out-of-pocket maximum, the amount at which Medicare starts to cover some prescription drug costs again. For generic drugs, only the actual amount you pay will count towards moving you out of the donut hole.

This discount will continue to grow until 2020, when the donut hole coverage gap is closed completely. In 2020 and beyond, you will just pay 25% of your drug costs until you reach the catastrophic coverage phase.

Preventive Services

Now, Medicare Part B covers more preventive services. Plans through Medicare Advantage also must cover preventive services. People on Part B are able to get a free wellness visit and personalized prevention plan each year. There are also no copayment, deductible, or coinsurance charges for recommended preventive services, like certain vaccines and cancer screening. Here is a list of the preventive screenings and services covered by Part B.

Health Insurance Marketplaces

Another option for health care is the health insurance marketplace, called Healthcare.gov. In Arizona, the marketplace itself is organized and regulated by the federal government, but it sells private insurance coverage plans. The plans available on Healthcare.gov are designed to offer more affordable options. They all are required to cover essential health benefits, so in this marketplace you can compare plans from different companies that offer similar benefits.

If you buy a plan through Healthcare.gov, in certain situations the government will help you pay your premium, meaning you pay less out of your own pocket. The government will help pay for your premium if you make less than 400% of the Federal Poverty Level (FPL), $48,560 for an individual in 2019 ($100,400 for a family of four) and can’t get affordable health coverage through your job.

You can also apply for some types of public health coverage, such as AHCCCS, through Healthcare.gov. If you qualify, you will be enrolled in a public program. If you do not qualify for a public program, you will still have the option of buying coverage on Healthcare.gov.

For more details on Healthcare.gov, read DB101’s article on Buying Health Coverage on Healthcare.gov.

Insurance Mandates for Employers
There is also an employer mandate, which requires all employers with 50 or more employees to offer affordable insurance to their employees or pay a fine. To learn more about the employer mandate, visit Health Reform information at the Kaiser Family Foundation.
Employers also cannot make an employee wait for more than 90 days before starting health coverage.

Note: It is very important to have health coverage, but starting in 2019 there is no tax penalty for individuals who don't have coverage.

Programs and Laws Which are Less Important Now

There are a few programs and laws that may change or fade away now that the ACA is fully in effect. This is because these programs or laws are no longer necessary, since the ACA provides the same, or better, protections.

  • High Risk Pools: These pools, such as the Pre-existing Condition Insurance Plans (PCIPs), offered people with pre-existing conditions a place to buy insurance. Since it is now illegal to deny someone insurance because of a preexisting condition, high risk pools are no longer necessary. If you were getting coverage through the PCIP, you will now be able to get private coverage on Healthcare.gov.
  • COBRA: This law allows you to continue your health coverage that you got through your employer after you leave your job. You are able to stay on the group plan, and continue to get group rates, for a certain period of time. Under the ACA, Healthcare.gov offers insurance not linked to your job, often for less money than COBRA.
  • HIPAA: This law protects a lot of different health-care related rights. Part of this law protects people with pre-existing conditions in a few different ways, such as requiring that people with pre-existing conditions be able to get employer-sponsored group coverage through their jobs. Because insurance companies are now required to offer insurance to anyone, the parts of HIPAA which protect people with pre-existing conditions are no longer necessary.