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Health Care Reform:

Health Insurance & Affordable Care Act

Managing the Cost of a Chronic Condition: FAQ

Health care costs can add up quickly when you have a condition that never truly goes away, like type 2 diabetes or heart disease.

Wondering how health reform affects what's covered and what you'll pay? Here are some answers.

Will my health insurance help pay for managing a chronic condition?

Most likely. All plans sold in the Marketplace, on the individual market, or through small employers must cover a list of essential health benefits, a rule that's part of the Affordable Care Act. The exception is grandfathered plans. Grandfathered plans are health plans that existed before the Affordable Care Act was signed on March 23, 2010, that have not substantially changed. Large employer health plans are not required to cover the essential health benefits, but most do.

One essential benefit is management for a chronic condition, such as asthma or diabetes. Most plans will help pay for:

  • Doctor office visits
  • Lab tests
  • Prescription medicines
  • Preventive care
  • Behavioral health services
  • Rehabilitation, including physical therapy and occupational therapy
  • Hospital care


Will any plan that covers essential benefits cover the same things?

Not necessarily. Each state can make decisions about what's covered. For each benefit, states decide what specific services and level of care the plans will cover. Each health plan for sale on the state's Marketplace must cover at least what the state chose.

Here are a few ways benefits can vary between states:

Look closely at the summary of benefits for any health plan you think you may enroll in.

How much of the costs for doctor visits and other care will my health plan cover?

That depends on what plan you choose and the specific design of the plan.

Your health plan has to limit the amount it charges you for your benefits. For plans bought through the state Marketplaces, you don't pay more than $6,600 for a single person and $13,200 for a family in 2015. Large employer plans have those same limits in 2015.

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