The Patient Protection & Affordable Care Act (ACA)
Paying for necessary medication or healthcare in general is often on of the biggest obstacles facing a disabled individual. Although Medicare now includes limited prescription drug coverage, Social Security Disability beneficiaries are not eligible for Medicare until 30 months after their first day of disability. The Patient Protection & Affordable Care Act (ACA) was passed into law with the purpose of making healthcare more affordable and accessible. For your convenience, Hermann Law Group has summarized some of the ACA’s key provisions and reforms that will directly affect Social Security Disability beneficiaries and provided useful links to help you find health insurance that fits your needs.
The Patient Protection & Affordable Care Act (ACA) – What Is It?
Passed into law in March 2010, the ACA makes preventative care – including family planning and related services – more accessible and affordable. The ACA requires that every individual have insurance, though there are some exceptions such as financial hardship or religious beliefs. Those who opt not to purchase health insurance will be required to pay a penalty. Therefore, in order to help individuals find and purchase affordable health insurance, the ACA requires the creation of state or multi-state based healthcare exchanges. This is commonly referred to as the Health Insurance Marketplace.
Low Cost Insurance Through The Health Insurance Marketplace
Beginning in October 2013, individuals will be able to shop for and enroll in a health care plan in their area that meets their needs. By submitting an application and enrolling1, individuals will be able to find out if they can get lower costs on monthly premiums for private insurance plans or if they qualify for lower out-of-pocket costs. The Health Insurance Marketplace will also tell individuals if they qualify for free or low-cost coverage available through Medicaid. Through the Health Insurance Marketplace, individuals can compare plans based on price, benefits, quality, and other important features before making a choice. For more information, call 1-800-318-2596 or visit www.healthcare.gov.
What If I Have A Pre-Existing Condition – Am I Still Eligible For Health Insurance?
Yes. No plan can turn you away or charge you more because you have an illness or medical condition. All plans must cover treatment for pre-existing conditions.
Where Can I Find A Health Insurance Marketplace In My Area?
To find the Health Insurance Marketplace in your area:
What If I Opt Out And Do Not Purchase Health Insurance?
Beginning in 2014, if an individual can afford health coverage, but chooses not to purchase it, they may have to pay a fee2. It is important to remember that someone who pays the fee will not get any health insurance coverage, and will still be responsible for 100% of the costs of their medical care.
Though the vast exception, certain uninsured individuals will not need to pay the fee. Some examples include people who:
are determined to have very low income and coverage is considered unaffordable (this applies if coverage costs more than 8% of your family’s income, and the cost of a family plan is taken into account)
are not required to file a tax return because their income is too low (the filing threshold is roughly $10,000 for individuals and $20,000 for married couples)
are uninsured for less than 3 months of the year
For more information, visit healthcare.gov.
What If I Cannot Afford Private Health Care Coverage In The Health Insurance Marketplace?
The Health Insurance Marketplace will tell individuals if they qualify for free or low-cost coverage available through Medicaid. Beginning in January 2014, financial eligibility for Medicaid will be expanded3. However, the Supreme Court of the United States made Medicaid expansion optional for states. New York, New Jersey, and Connecticut have all implemented Medicaid expansion. To see if you are eligible for Medicaid, visit and enroll in the Health Insurance Marketplace in your area.
What If I Cannot Afford Health Insurance But I Am Also Not Eligible For Medicaid?
Such an individual can get free or low-cost health and dental care at community health centers in their area. The amount you pay depends upon income and may provide:
general primary care
specialized care for more serious conditions, like mental health, substance abuse and HIV/AIDS
prenatal care and baby shots
To find a community health center in your area, visit findahealthcenter.hrsa.gov.
Other Private Insurance Reforms
For people with disabilities, the most important reform is likely the prohibition against denying coverage based on pre-existing conditions. However, the ACA implements a number of other crucial reforms that will have a direct impact on the disabled. Some notable examples include:
- The elimination of lifetime dollar limits and annul dollar limits from all health insurance plans;
- Insurance plans may not rate premiums differently based on gender, health status, past claims experiences, or industry. Beginning in 2014, health insurance premiums may only vary by age, tobacco use, geography and whether coverage is for an individual or family;
- Guaranteed issue and renewal of policies, and waiting periods for insurance coverage of no more than 90 days.
For more detailed information, visit ncsl.org.
What If I Am Awarded Disability Benefits – Do I Still Need To Purchase Health Insurance?
Disability beneficiaries are entitled to begin receiving Medicare 30 months after their first day of disability (or once they turn 65). Unless an individual is eligible for Medicaid, he/she must purchase coverage through a Health Insurance Marketplace during the interim in order to avoid paying a fee. The majority of people receiving supplemental security income are eligible to receive Medicaid.
1 Open enrollment ends on March 31, 2014. After this date, an individual will not be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event.
2 The fee in 2014 is 1% of an individual’s yearly income or $95 per person, whichever is higher. The fee increases every year. In 2014, the fee for uninsured children is $47.40 per child. The more a family would have to pay in 2014 is $285.
3 Financial eligibility for Mediciad will be expanded by requiring participating states cover nearly all adults under age 65 with household incomes at or below 133% of the federal poverty level (FPL). To see whether your family’s income is at or below 133% of the FPL, visit familiesusa.org