How Health Reform Affects Arthritis Care Costs

Health care reform offers help for people with chronic conditions like rheumatoid arthritis or osteoarthritis. Under the Affordable Care Act, you are guaranteed care for these conditions. You'll also have access to medicine and pain treatment, if you need it.*

If you have a child with a chronic condition, such as juvenile arthritis, your child cannot be turned down for insurance. Your child can stay on your insurance plan until age 26, for much longer than before the Affordable Care Act.

Arthritis Coverage

Under the Affordable Care Act, you can get or keep insurance coverage after you or your child is diagnosed with arthritis. This is because:

  • You cannot be turned down for health insurance because of your arthritis.
  • You can buy an insurance policy just for your child, even if he or she has arthritis.
  • Your insurance cannot be canceled because you develop arthritis.
  • Your children must be covered by your insurance if you choose to include them on your policy. This is true even if a child already has arthritis.
  • Since the start of 2014, you must be allowed to buy a health plan from any insurer even if you have arthritis.
  • All of your children can stay on your health plan until they reach age 26 if your health plan offers dependent coverage.

You may also benefit from rules that limit how much you will pay for your care or medicines. For instance:

  • You will not have an an annual lifetime or dollar limit on how much a health plan spends on your care. Annual and lifetime limits have gone away.
  • If you are sick, you can't be charged more for health insurance.
  • Your out-of-pocket costs will be limited. Health plans must place a cap or a maximum on how much you spend on your care. Once you reach that amount, your insurance company covers the rest of your costs. That includes what you would spend on copays and deductibles for medical care and prescriptions.

Paying for Arthritis Medicine

Prescription drug coverage is one of 10 essential health benefits under the Affordable Care Act. That means it must be part of any policy that you buy through your state's health insurance Marketplace, on the individual market, or what's offered by a small employer

 

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Managing Pain

You may benefit from other essential health benefits. For instance, to care for your arthritis you may need:

If you're on Medicare, your coverage also includes the essential health benefits. So does Medicaid if you qualified because your state expanded Medicaid. Also, any plan you buy through your state's insurance Marketplace, on the individual market, or through a small employer must offer these benefits. If you get insurance through your job, check your health plan to confirm the details of your coverage. Large employers -- those with 50 or more employees -- do not have to cover the essential health benefits although the vast majority do.

Related Care

Your arthritis may lead to other health issues. The Affordable Care Act can help with some of the care you may need to treat those conditions, too.

For instance, you can get a free screening for depression. This is part of your preventive care benefits. Check with your health plan for details on how to use this resource.

You will also be able to get free counseling on healthy eating. Losing weight can ease arthritis pain.

Savings on Drug Costs for Seniors

If you're on Medicare and take medicine for arthritis, you may be pleased to know that the donut hole -- the gap in Medicare coverage for prescription drugs -- is slowly going away. It will be gone by 2020. Then you will only pay 25% of the cost of your brand-name and generic medications until you hit a yearly limit. See "What Medicare Costs, Part D" to get the details, including what discounts are available until the donut hole closes.

*The exceptions to these requirements are “grandfathered” plans -- health plans that existed before March 2010 that have not made any significant changes to their benefits -- and short-term health plans -- those that provide coverage for less than one year. Grandfathered and short-term health plans do not have to offer coverage for essential health benefits. If you are not sure whether your health plan is grandfathered or a short-term health plan, call your insurance company. 

WebMD Medical Reference Reviewed by Sarah Goodell and Lisa Zamosky on July 22, 2019

Sources

SOURCES:

Arthritis Foundation: "Health Care Reform."

American Society of Anesthesiologists: "Pain Medicine."

U.S. Preventive Services Task Force: "USPSTF A and B Recommendations."

Community Catalyst and the Center for Health Insurance Studies, Georgetown University Health Policy Institute: "Essential Benefit Package."

Medicare.gov: "Closing the Coverage Gap - Medicare Prescription Drugs Are Becoming More Affordable."

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