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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 must cover a list of essential health benefits, a rule that's part of the Affordable Care Act. The exception is grandfathered employer plans. Grandfathered plans are older health plans that existed before the Affordable Care Act was signed on March 23, 2010. Those older plans don't have to cover essential benefits.

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

  • Doctor office visits
  • Lab tests
  • Certain prescription medicines
  • Preventive care
  • Behavioral health services
  • Rehabilitation, including physical therapy and occupational therapy
  • Hospital care, if you need it

All plans available on your state's Marketplace , also called an Exchange, must cover care for chronic conditions. If you get insurance through a small employer, you should also be covered.

Health plans through large employers are not required to cover all of the essential health benefits. However, many offer coverage for these conditions already.

Not sure if your company is considered large? If you work for a company with about 50 to 100 employees, check with your HR department. The company's size depends on how many part- and full-time workers work there.

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 won't have to pay more than $6,350 a year for one person or $12,700 a year for a family in 2014. The same limits will be in place for all employer plans by 2015.

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