Health and Wellness: The Affordable Care Act and You

Major Changes In Healthcare Will Affect the MS Community – Are You Ready?

by Margaret Weisser, LSW
Edited by Peter Damiri

The Affordable Care Act (ACA) aims to increase the availability and affordability of health insurance for millions of Americans who lack coverage. The ACA initially began making changes in 2010; however, beginning in January 2014, this historic initiative will significantly impact a substantial number of individuals with multiple sclerosis (MS) and their families.

A number of changes have been made to the entire health-insurance system, not only in terms of greater access to insurance, but also with how insurance will be regulated and minimum standards of coverage. Open enrollment begins on October 1, 2013. While most Americans with manageable healthcare needs will find sufficient information regarding coverage options through state and federal resources, the MS community must be prepared to ask additional questions to ensure proper coverage.

As many of you know, MS is a highly individualized and expensive disease to evaluate, manage, and treat. Individuals with MS must consider an extraordinary number of factors when determining their healthcare coverage, including: the ability to access neurologists and other treating specialists; policy selections that impact the costs of deductibles, co-pays, and co-insurance; and drug formularies that classify MS medications in various tiers, limiting access and restricting changes. Similar complexities and changes will potentially impact the costs of magnetic resonance imaging (MRI) scans, rehabilitation services, and adaptive equipment.

What if You Have Insurance Already?

Many individuals who have insurance currently may be thinking, “Will the ACA impact me?” The answer for almost everyone is a resounding, “Yes!” Some of the overarching benefits put into place by the ACA will assist all individuals with MS. These include the removal of pre-existing conditions, the elimination of dollar limits on annual and lifetime benefits for healthcare coverage, and benchmark plans that set minimum benefits standards on a broad array of health services.

Medicare recipients will see some changes in their out-of-pocket expenses as the Medicare Part D donut hole, which covers prescription medications, is incrementally lowered to finally “close” in the year 2020. At that time, Medicare recipients will pay 25 percent of the drug cost. This represents a significant cost savings, as before 2010, individuals in the donut hole were required to pay 100 percent of the cost of their medications until reaching the end of the donut hole.

Medicaid will also see changes as many more individuals on a low-income budget will become eligible for Medicaid. At the time this article was written, 27 states have already agreed to expand their Medicaid programs to include individuals up to 138 percent of the federal poverty level (FPL), which is $15,415 per individual or $26,344 per family of three in 2012. It is important to note that some states only expanded the Medicaid program for particular groups and not all individuals under the 138-percent FPL. Additionally, as of March 2013, seven states are still undecided on whether to expand the Medicaid program.

For individuals who live on a very limited budget, your residence may actually dictate what insurance resources may be available to you. If you are not sure whether you may qualify for Medicaid services beginning in January 2014, you will be able to find out directly through your state’s Marketplace. When you input your income into the system, the Marketplace will identify whether you qualify for Medicaid in your state. If you qualify, your enrollment information will be sent directly to the correct state office.

Private insurance or employer-based insurance offers new options as well. Individuals who purchase insurance or receive insurance through an employer will also have new coverage options as Health Insurance Marketplaces (formerly Exchanges) open up to create an arena in which to shop for the best insurance policy. Employers with 50 or more full-time equivalent employees must automatically register their employees for health insurance or pay a penalty. An employee can opt out of their company health-insurance plan in writing and formally choose to enter the Health Insurance Marketplace.

The Health Insurance Marketplace is an entirely new entity with 18 states choosing to independently run their own Marketplace, seven states selecting to provide a partnership Marketplace with the federal government, and 26 states opting to default to the federal government to run their Marketplace. The Marketplace is largely a web-based comparison platform (similar in concept to Orbitz or Travelocity) where people can enter their personal information and receive comparison data on health-insurance plans. Individuals will be able to compare the cost of the monthly premiums, deductibles, and expected costs and co-insurance fees for common procedures, medical equipment, and medications. If you do not have computer access, you will have opportunities to enroll by phone and in person.

Most plans offered through the Marketplace include three levels of service. They are commonly defined as:

Bronze: lower premiums, but higher out-of-pocket costs for health services

Silver: higher premiums than bronze, but more moderate out-of-pocket costs for health services

Gold: highest monthly premiums, but lowest out-of-pocket medical costs for health services

So, Why Do You Need to be Concerned?

Most individuals with average healthcare needs will be able to enter the Marketplace and locate a suitable plan within their price range. For individuals who purchase insurance in the Marketplace, many will qualify for a monetary credit to assist with their monthly premiums. This credit is determined when a person’s income is entered into the Marketplace website. It is important to remember that if your income changes during the year, you must re-enter the Marketplace and update your income, as this might affect your coverage.

Individuals with MS need to consider many factors when selecting a plan that go far beyond the cost of the monthly premium. The challenges presented by a complex, chronic illness such as MS will require you to pay close attention to many areas of coverage, including the items listed below.

Medications: Medications that are specific to MS (the disease-modifying therapies and some symptom-management treatments) are considered specialty drugs. As a result, most of these medications are classified as Tier 3 or Tier 4, which indicates they have the highest co-pay levels. You will need to evaluate not only the cost of the co-pay or co-insurance for medications on those tiers, but also directly check with each insurance policy you are considering to see which MS medications are currently covered on that insurance drug formulary.

You should consider not only your current drug therapy, but what other medication(s) would be available to you if you need to change drug protocols. Plans that cover fewer MS medications may be less desirable. Also, plans may list many of the MS medications as a “Step Therapy,” which means you must fail another identified treatment option to qualify for that medication. Another important factor to understand and remember is that insurance companies can change their drug formularies at any time. The companies are required to notify customers of these changes, but it is in your best interest to inquire about the drug formulary when you renew your policy.

Diagnostic and follow-up testing (such as MRI): If specific tests, such as an MRI, are typically used in the management of your health conditions, you will want to evaluate how that procedure is covered to project out-of-pocket expenses. This entails evaluating the cost of the monthly insurance premium for plans at different coverage levels versus what the expected co-pay, co-insurance, and deductible costs will be for procedures or testing you may need on a regular basis.

Durable Medical Equipment (DME): Many individuals with MS may utilize DME’s such as canes, walkers, wheelchairs, lifts, and scooters. If you know you need to replace an existing item or are looking to obtain multiple items to improve daily living, you should pay close attention to how these items are covered under the policy. This will ensure that you will have the coverage needed to obtain any items you may require.

Please make sure that you select wisely. If you select the “wrong” plan, you may not be eligible to change insurance policies again until the next open enrollment or until a specific qualifying “life-change” event takes place. Therefore, it is especially important to make the best choice possible based on your individual needs and circumstances.

These are just a few of the areas you may want to consider when selecting the best Medicare, Medicaid, or insurance plan for your specific needs. For more information and details about what you need to know, please visit the ACA section of MSAA’s website at On the website, we offer a list of common insurance terminology, how to navigate drug formularies for MS medications, a checklist of important questions to ask before purchasing a policy, and more. Anyone with additional questions may speak with an MSAA Helpline consultant by calling (800) 532-7667, extension 154. Questions may also be emailed to