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Affordable Care Act benefits MS patients

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Director of Advocacy at the Greater Northwest Chapter of the National Multiple Sclerosis (MS) Society Jim Freeburg is educating people about the many advantages of the Affordable Care Act (ACA), including people who have MS.


During the MC/Cancer telephone support group meeting on September 25th Freeburg said, “The existing health care industry in this country is badly broken for people with chronic diseases, is not available for everyone and is not coordinated. Those are some of the many reasons why the reformed health care law was enacted in 2010.”


Universal coverage is important because everyone becomes ill at some point. When someone doesn’t have health care coverage, everyone else has to pay for his or her care through higher premiums.


Individual Mandate

The ACA requires everyone to have health care insurance, called the Individual Mandate. If you are insured through your job, Medicaid or Medicare, you are not required to make a change. If you are uninsured, you must purchase insurance for yourself or pay a tax. If the health care policy costs more than 8 percent of your household income, you are exempt and will not have to pay a penalty.


Subsidies are available to people with low and moderate incomes (by percentage of federal poverty level). For example, a family of four that earn $92,000 or less will receive sliding scale discounts to the cost of the insurance policy.


ACA and People with MS

The Affordable Care Act, often referred to as Obamacare, will help people with MS and other chronic diseases.


The National MS Society has advisors to help individuals to make decisions and the ACA. Many states have benefits advisors that are well-trained volunteers to help people figure out their options. Call the Society at 1-800-344-4867 for more information, Freeburg said.


The following are highlights of benefits and details of the ACA.


Advantages of the Affordable Care Act

No lifetime or annual caps

·      As of 2010, the lifetime caps on health insurance benefits are eliminated.

·      A health insurance plan will not be able to drop your coverage.

·      Annual caps on health benefits started to be phased out beginning in 2010.


No pre-existing conditions

·      As of 2010: children (ages 0-18) cannot be denied coverage based on pre-existing conditions.

·      Starting in 2014: No one can be denied insurance due to pre-existing conditions.

·      Starting in 2014: No one can be charged more because of health history or condition.

·      Only three things lead to higher premiums: age, tobacco use and geography.


Free Preventive Care

·      Preventive care includes annual well check-ups, routine care, vaccines, birth control, mammograms, colonoscopy and screenings.

·      As of 2010: Children, seniors and disabled on Medicare receive preventive care free with no co-payment.

·      Aug 1, 2012: Women can receive contraceptives and well-woman care free with no co-payment.

·      Starting in 2014: All insured adults and kids get free preventive care with no co-payment.


Health care availability and coverage

·      Starting in October 2013, most people who do not have health insurance will be able to sign up for coverage that takes effect in January 2014.


·      Insurers will no longer be able to deny coverage or charge more because of a pre-existing condition like MS or any health problem. If you had coverage that was limited or cost more due to your pre-existing condition, these limits and higher rates will be eliminated.


·      Every health insurance plan in the new Marketplace will offer comprehensive coverage, including hospitalization, doctors’ visits, prescriptions and more. You can compare all your insurance options based on price, benefits, quality and other features that may be important to you.


·      All health insurance, Medicare and Medicaid plans must cover recommended preventive care such as cancer screenings and vaccines at no additional cost to you.

·      Shopping for coverage will be easier when the new Health Insurance Marketplaces (or Exchanges) start up in October 2013. You can apply for coverage online, over the phone, by mail and in person in some places.

·      One-to-one help will be available from new Navigators who are health insurance counselors offering un-biased information, education and enrollment assistance to consumers at no cost.


·      Tax credits and other help with costs will make coverage more affordable for individuals, families and small businesses.


Regulating Insurers

The ACA has built-in limits on insurers. Insurers have to spend 80 percent of premiums on health care. Only 20 percent can go to overhead and profits.


Any health insurance increase 10 percent or more goes through an automatic review process on whether or not the increase is justified. It is up to states as to whether unjustifiable rate increases can be stopped.


Essential benefits of the Affordable Care Act

Starting in 2014, through the Affordable Care Act, all health insurance policies will cover these essential health benefits:

1.    Ambulatory patient services

2.    Emergency services

3.    Hospitalization

4.    Maternity and newborn care

5.    Mental health and substance use disorder services, including behavioral health treatment

6.    Prescription drugs

7.    Rehabilitative and habilitative services and devices

8.    Laboratory services

9.    Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care.


Understanding Changes to Medicare

Roughly one quarter of all people with MS rely on Medicare as their primary source of health insurance. The Affordable Care Act (ACA) makes some changes to Medicare that can be particularly helpful for beneficiaries living with MS. Learning about these changes will give you or your family member with MS peace of mind about your Medicare benefits and costs.


The following lists conditions that do not change for Medicare beneficiaries:

·      You can continue to use your same doctors, hospital and pharmacies.

·      You still can coordinate your Medicare benefits with other coverage you have such as a retirement health plan, Medigap policy or Medicaid.

·      You still can switch Medicare prescription drug (Part D) or Medicare Advantage plans if you need to under certain circumstances.


Facts concerning the ACA and Medicare

·      The prescription drug coverage gap or “donut hole” is being phased out. In 2013, the coverage gap begins when total prescription drug costs reach $2,970, and ends when total costs reach $4,750. (During the gap, beneficiaries must pay the full cost of their medications.) The ACA gradually eliminates the coverage gap by providing automatic discounts for any drugs needed during the gap period. In 2013, brand name drugs needed during the gap are discounted by more than 50 percent.

·      Medicare now covers certain preventive services, such as screening mammograms, colonoscopies, bone density tests and more – at no cost to the individual. No deductibles or copayments are required for these and other recommended tests and vaccines that help keep people healthy. An individual also can get an annual wellness visit (or check-up) at no additional cost.

·      Many doctors, hospitals and other providers are taking advantage of new programs to help them work better as teams that share information quickly and easily. The new law encourages these arrangements and will continue to evaluate new ways of paying for care that are meant to provide you with the best quality care possible while reducing inefficient or ineffective treatments.

·      The ACA builds on efforts to combat fraud and abuse in Medicare, saving billions for taxpayers. As a result, the trust fund that finances the Medicare program will be more financially secure.


Learn more about the new law at, the official website of the Affordable Care Act.  You can use this site to sign up for free updates by email or text or ask questions through the online chat or toll-free service.


Source: National Multiple Sclerosis Society website at

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