How Health Reform Affects Disability Care

If you have a disability -- or your child does -- you can't be turned down for insurance* because of the disability. You may pay less for care. You may also have greater access to the treatment you need.

Both physical and mental disabilities qualify. Some examples include:

  • You had a stroke and it has affected your speech, vision, or movement.
  • Your child is a young adult with autism spectrum disorder that has kept him or her from getting a job and living independently.
  • You have a slipped disc that makes it impossible for you to work.
  • You have bipolar disorder, which has kept you from getting or keeping a job.

Essential Health Benefits

By law, all health plans* sold in state Marketplaces, on the individual market, or through small employers must cover a list of 10 "essential health benefits." This includes care that can help you manage your disability. These benefits include:

  • Rehabilitation services. This is a type of treatment that helps you regain function you lost because of your condition. You can also get habilitative services, treatment that helps you learn and develop skills important to your daily life.
  • Mental health services. Insurers must cover counseling for mental illnesses like bipolar disorder or schizophrenia. You can also get medicine for your condition. And you can get a screening for depression without having to pay an additional cost for the visit.
  • Chronic disease management. You can get help managing chronic health conditions such as arthritis and heart disease.

Insurance companies that sell health plans through your state's insurance Marketplace must include these essential health benefits. Older health plans with “grandfathered” status don't have to cover the essential health benefits package. Neither do large employer plans, though most cover them anyway. Be sure to check the details of what your plan covers before seeking care.

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Other Protections

The Affordable Care Act protects your insurance coverage in several ways:

  • You cannot be dropped from your plan because you have a disability.
  • Your plan must cover your child, even if the child has a disability.
  • You cannot be turned down for coverage if you have a disability.
  • Your children can stay on your plan until they reach age 26.
  • Your plan cannot include a dollar limit on care.  Annual and lifetime limits go away.
  • You cannot be charged more for insurance because you are sick or disabled.
  • Your out-of-pocket costs are capped. There's a limit on how much you will spend each year. After reaching that amount, your plan covers all costs. That includes copays and deductibles.

 

 

Getting Coverage

If you use the Marketplace to shop for health insurance, you will be able to see what health care plans are available to you, the cost of the plans, and whether you qualify for help with your costs. You must shop for insurance and enroll in a health plan during your Marketplace’s annual open enrollment (November 1 – December 15 in most states). Outside of this period you cannot sign up for a new plan or change plans unless you have a “life event” that qualifies you for a special open enrollment period.

The Marketplace is not for you if you’re already covered by Medicare or Medicaid, or if you have a health plan through your employer.

Eligibility for Medicaid varies greatly from state to state. In states that expanded Medicaid under the Affordable Care Act, you will qualify if you earn $16,753 or less a year or $34,638 for a family of four (in 2018). If you qualify for Supplemental Security Income because of your disability, you will generally qualify for Medicaid coverage in your state. 

You should check with your state's Medicaid agency or your state Marketplace to find out the details. Unlike health insurance available through the Marketplace, you can sign up for Medicaid at any time during the year.

You should check with your state's Medicaid agency to find out the details.

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Helping You Live Independently

If you are struggling to live on your own with a disability or care for a relative who is disabled, the Affordable Care Act may help. The law expanded Medicaid programs that provide in-home care and help you avoid moving to a nursing home. The expansion of Medicaid’s Home and Community-Based Service options can help you stay independent or provide care for a loved one. In general, these services are only available to people who qualify for Medicaid.

Savings on Drug Costs for Seniors

The gap in Medicare coverage for prescription drugs – also called the donut hole -- is slowly going away. By 2020, you'll pay only 25% for covered brand-name and generic medications once you meet the plan’s deductible. See "What Medicare Costs, Part D" to get the details, including what discounts are available until the donut hole closes.

*Grandfathered health plans and short-term health plans (those offering coverage for less than 12 months), can deny coverage for people with pre-existing conditions and do not have to offer all the benefits and protections of the ACA.

WebMD Medical Reference Reviewed by Sarah Goodell on September 18, 2018

Sources

SOURCES:

American Association of People with Disabilities: "Health Reform and People With Disabilities."

The Arc: "The Affordable Care Act: What Disability Advocates Need to Know."

U.S. Department of Health & Human Services: "Affordable Care Act for Americans with Disabilities."

World Institute on Disability: "Affordable Care Act (ACA) Summary and Updates."

Social Security: "Disability Evaluation Under Social Security."

National Association of Insurance Commissioners: "Glossary of Health Insurance and Medical Terms.

U.S. Department of Labor: "Frequently Asked Questions."

National Women's Law Center: "Women's Preventive Services in the Affordable Care Act: Frequently Asked Questions."

Medicare.gov: "More savings in the drug coverage gap coming through 2020."

HealthCare.gov: "Costs in the Coverage Gap."

North Carolina Stroke Association: "Applying for Disability Benefits After a Stroke."

American Physical Therapy Association: "Essential Health Benefits (EHBs.)"

HHS.gov: "Affordable Care Act for Americans with Disabilities."

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