Expanding Coverage by Reforming the System

Before 2010, about 50 million Americans did not have any sort of health insurance. The Affordable Care Act of 2010 (ACA) is a law that has expanded the health care system that was already in place in the United States in order to make coverage available to more Americans. A big misunderstanding that people have is that the ACA created a government-run health care system. This is not correct. The ACA built off of public and private insurance systems that were already there, to get coverage to more people. For the most part, the ACA has not drastically changed our nation’s health care system. You can think of this law as a patchwork solution that created many new patches to cover the gaps, rather than creating a brand new approach.

This overview article highlights some of the main ACA reforms that impact you directly. We will not cover all of the reforms of the ACA in detail here. If you are interested in learning more about the ACA, you can start at Health Reform information at the Kaiser Family Foundation.

New Coverage Options

In the past, one of the main ways you could get health insurance was through a job that offered it. If you lost your job, you might lose your insurance. Now, your ability to get health coverage is no longer tied to your job, because there are other health care options. However, most people will continue to be covered through their jobs, as before.

Today, insurance options fall into three main groups:

1. Public coverage: These are health coverage plans provided by the government. Usually, you qualify for public plans based on some sort of criteria (for example, low income, pregnancy, age, or disability). Medicare and Medical Assistance are the largest public health programs. Public coverage expanded under the ACA.
2. Private coverage: This is insurance sold through a private company. Private insurance can be offered through an employer, or you can buy it directly from the insurance company. Under the ACA, there are consumer protections that give people more access to private coverage and limit the costs of private plans. There are also marketplaces in each state for buying private coverage, known as health insurance marketplaces. In Minnesota, this marketplace is called MNsure. These health insurance marketplaces offer a place for individuals and small businesses to buy coverage which meets set standards of quality.
3. Private coverage subsidized by the government: In the past, many people could not afford to buy private coverage. Now, under the ACA, if your income is low, you can qualify for a government subsidy, which means that the government will help you pay for a private insurance plan.

Rights and Protections for Consumers

Another major part of the ACA is that it created many new rights and protections for consumers who use health insurance. For example, it is illegal for insurance companies to deny people coverage because they have a pre-existing condition. There is more information about patient rights later in this article.

Insurance Mandate for Employers

There is an employer mandate which requires employers with 50 or more employees to offer affordable insurance to their employees, or pay a penalty.

Note: It is very important to have health coverage, but starting in 2019 there is no tax penalty for individuals who don't have coverage.

Existing Medical Assistance (MA) Programs

There are some changes that happened in Medical Assistance (MA), but they are changes that expanded coverage to more people, and did not take it away from anyone. You can read more about the changes later in this article.

If you were on MA before the ACA, you are able to keep the coverage and benefits that you already had.

Existing Medicare Programs

If you were on Medicare before health care reform, your coverage didn't change. Your benefits have stayed the same, whether you are on Original Medicare or Medicare Advantage.

The Affordable Care Act (ACA) did make some small changes to Medicare. You can read more about these changes later in this article.

Employer-Based Coverage

Under the ACA, most employers are required to provide coverage or pay a fine if they don’t (small businesses with fewer than 50 employees won’t have to pay a fine).

In general, you will be able to keep your employer-based coverage as long as your employer chooses to keep offering it. Just like before health care reform, most Americans still get their health coverage through an employer.

However, if your employer decides to stop offering coverage, there are other options not based on your job, such as MNsure.

For more information on employer-based coverage, read the DB101 article on Employer-Sponsored Coverage.

Patient Rights and Protections

The ACA created many rights and protections for health insurance consumers. Some of these rights were already granted to residents of Minnesota through state law, but those rights are now federally protected for everyone in the country. Other rights were brand new under the ACA.

Limits on Insurance Companies

One of the most important rights under the ACA is that it is illegal for insurance companies to deny you coverage because of a pre-existing condition. In the past you could be turned down because of a disability, a previous illness, a mental health diagnosis, or any number of other pre-existing conditions. Now insurance companies have to offer plans to everyone.

Also, insurance companies cannot drop your coverage when you get sick. Before the ACA, this was happening to thousands of Americans each year. Insurance companies are not allowed to put annual or lifetime limits on your essential benefits, which include things like hospital stays, prescription drugs, and doctor’s visits. This means that they cannot stop paying for your care because they decide it costs too much.

Insurance companies can’t charge higher rates because of health, gender, or other factors. Higher premiums are allowed based on age (but limited to no more than three times the amount charged for young people), geography, family size, and tobacco use. Also, children can stay on (or be added to) their parents’ insurance policies until they turn 26, if they can’t get insurance through a job of their own.

If your insurance company makes a decision about your care that you disagree with, including denying a claim, you have the right to appeal the decision, both with the insurance company and with an independent agency.

Also, insurance companies are required to spend at least 80% of all the money they get from premium payments on health care services and quality improvement. If insurance companies don’t meet these percentages because their costs or profits are too high, they have to give money back to their customers.

Preventive Health Coverage

Insurance companies now have to cover certain preventive services, like cancer and diabetes screenings. Insurance companies are required to offer these services free to the patient - without deductible, coinsurance, or copayment charges.

The law also ensures that many preventive health services for children are free, including well-baby and well-child visits up to age 21 and many vaccines.

People with Disabilities

There are many protections and rights in the ACA that affect people with disabilities. Protections such as the ban on rejecting people’s insurance applications because of a pre-existing condition make it easier for people with disabilities to get insurance.

There are also some parts of the law that directly address disability issues in health care. The Access Board is a group that develops accessibility standards to meet the requirements of the Americans with Disabilities Act (ADA) and other laws. The ACA asked the Access Board to come up with accessibility standards for medical equipment. The standards are supposed make it as easy as possible for people with disabilities to use medical equipment. For more information, visit the Access Board’s website.

Medicaid

Expanded Medical Assistance (MA)

As mentioned earlier, if you were on Medical Assistance before the ACA, you are able to keep your coverage.

However, there were some changes that expanded MA coverage to people who weren’t able to get MA coverage before. It covers more low-income people, including adults without children, and adults without a disability. People with incomes up to 138% of the Federal Poverty Guidelines (about $20,783 for an individual or $43,056 for a family of four) are able to get MA. The expansion also got rid of asset limits for people in the new eligibility group.

For more information on MA, read the DB101 article on MA.

Improvements to Home and Community-Based Services (HCBS)

In State, MA has programs that allow people with disabilities who need a certain level of care to get that care at home, instead of in an institution. You, as the consumer, have the right to select and train attendants that meet your personal needs and preferences. You have the right to dismiss your attendant if you are not happy with the care you are receiving. You can also choose a family member to provide these services (except a spouse or legal guardian).

Community-based services include:

• Attendant services to support the activities of daily living
• Safety monitoring
• Assistance with learning skills to accomplish activities of daily living more independently
• Training in how to choose, manage, and dismiss attendants

There are options under MA that make it easier to get long term care at home. To learn more about home and community-based services, read the DB101 article on MA for People with Disabilities.

MinnesotaCare

MinnesotaCare has provided insurance to low-income Minnesota residents for decades. In 2014, the program expanded coverage to many more people. The changes to MinnesotaCare play an important part in the larger picture of health care reform. MinnesotaCare provides insurance options for people with income that is too high to qualify for Medical Assistance, but too low to afford private insurance through MNsure. If your income is between $20,783 and $29,160 (for an individual), you may be able to get insurance through MinnesotaCare.

The changes to MinnesotaCare help make it easier to get insurance through this program. For example:

• There are no longer asset limits
• There is no longer a requirement that you have to be uninsured for 4 months before getting MinnesotaCare
• There are no longer caps on the benefits you can get
• Premiums are lower for many people

To learn more about MinnesotaCare, read DB101's MinnesotaCare article.

Medicare

As mentioned before, it is important to know that if you were already on Medicare (Original Medicare or Medicare Advantage) before the ACA, your coverage and benefits did not change. New enrollees to Medicare are able to get the same benefits as people already on Medicare. However, there have been a few changes to Medicare.

Closing the Donut Hole

In the past, Medicare Part D has had a gap in prescription drug coverage called the “donut hole.” Under Medicare Part D, when a person’s prescription drug costs reach a certain amount ($5,030), Medicare stops paying for any of their prescription drug costs. The person has to pay for their drugs out-of-pocket, until they reach the maximum out-of-pocket amount ($8,000). Once they reach this maximum, they are out of the donut hole and Medicare starts to help cover the costs again. Before the ACA, a person had to pay for 100% of their prescription drug costs while in the donut hole.

Since the ACA, this has changed. Each year, people on Medicare who fall within the donut hole get a discount on their prescription drugs, to help cover their out-of-pocket costs while in the donut hole. The discount gets larger each year. In 2024 the discount is 75% for brand name prescriptions and 75% for generic drugs. The full cost of brand name drugs (rather than the discounted amount) will still count towards the person’s out-of-pocket maximum, the amount at which Medicare starts to cover some prescription drug costs again. For generic drugs, only the actual amount you pay will count towards moving you out of the donut hole.

This discount will continue to grow until 2020, when the donut hole coverage gap is closed completely. In 2020 and beyond, you will just pay 25% of your drug costs until you reach the catastrophic coverage phase.

Preventive Services

Now, Medicare Part B covers more preventive services. Plans through Medicare Advantage also must cover preventive services. People on Part B are able to get a free wellness visit and personalized prevention plan each year. There are also no copayment, deductible, or coinsurance charges for recommended preventive services, like certain vaccines and cancer screening. Here is a list of the preventive screenings and services covered by Part B.

Health Insurance Marketplaces

Another option for health care is the health insurance marketplace, called MNsure. The marketplace itself is organized and regulated by the Minnesota state government, but it sells private insurance coverage plans. The plans available on MNsure are designed to offer more affordable options. They all are required to cover essential health benefits, so in this marketplace you can compare plans from different companies that offer similar benefits.

If you buy a plan through MNsure, in certain situations the government may help you pay your premium, meaning you pay less out of your own pocket. The government may help pay for your premium if you can’t get affordable health coverage through your job and don't qualify for other public coverage options. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

You can also apply for some types of public health coverage, such as Medical Assistance and MinnesotaCare, through MNsure. If you qualify, you will be enrolled in a public program. If you do not qualify for a public program, you will still have the option of buying coverage on MNsure.

For more details on MNsure, read DB101’s article on Buying Health Coverage on MNsure.

Programs and Laws Which are Less Important Now

There are a few programs and laws that may change or fade away now that the ACA is fully in affect. This is because these programs or laws are no longer necessary, since the ACA provides the same, or better, protections.

• High Risk Pools: These pools, such as MCHA, offered people with pre-existing conditions a place to buy insurance. Since it is now illegal to deny someone insurance because of a preexisting condition, high risk pools are no longer necessary. MCHA closed at the end of 2014. If you were getting coverage through MCHA, you will now be able to get private coverage on MNsure.
• COBRA: This law allows you to continue your health coverage that you got through your employer after you leave your job. You are able to stay on the group plan, and continue to get group rates, for a certain period of time. Under the ACA, MNsure offers insurance not linked to your job, often for less money than COBRA.
• HIPAA: This law protects a lot of different health-care related rights. Part of this law protects people with pre-existing conditions in a few different ways, such as requiring that people with pre-existing conditions be able to get employer-sponsored group coverage through their jobs. Because insurance companies are now required to offer insurance to anyone, the parts of HIPAA which protect people with pre-existing conditions are no longer necessary.