Health Insurance Reforms in the Affordable Care Act (ACA)

• Eliminates pre-existing condition exclusions
• Bans annual and lifetime limits
• Ends the practice of rescissions (insurance coverage is cancelled when a person develops a serious health condition)
• Improves appeals process including independent reviews
• Requires that 80% of health insurance premium dollars are paying for health care
• Enhances state capacity to regulate unfair increases in insurance rates
• Prohibits considering health status in calculating premiums (2014)
• Requires guaranteed issue and renewals (2014)
• Prohibits discrimination based on health status (2014)

The ACA Expanding Access to Coverage

• Establishes temporary high risk pools to cover those who are currently uninsured (until 2014)
• Allows coverage for dependents until age 26
• Creates health insurance Exchanges for individuals and small employers to purchase insurance (2014)
• Provides significant subsidies to assist low income individuals to purchase coverage in the Exchanges and provides tax credits to help small employers
• Includes coverage of dental and vision care for children in the Exchanges
• Includes mental health services, rehabilitative and habilitative services and devices, and other critical disability services in the health plans sold in the Exchanges

The ACA Expands Medicaid

• Expands Medicaid eligibility to 138% of the federal poverty level
  • New method of income disregards
  • No asset test
• 16 million new beneficiaries by 2019
• Federal government pays 100% till 2016 (phase down to 90% in 2020)

The ACA and Long Term Services and Supports

• Establishes the Community First Choice Option for states to cover comprehensive community attendant services under the state’s optional service plan
• Improves existing Section 1915(i) option for home and community based services
• Creates a new state balancing incentives to reduce institutional bias of Medicaid
• Extends “Money Follows the Person” Demonstration
• Authorizes the CLASS program

Other Medicaid and Medicare Improvements

• Gives states the option to provide health homes for Medicaid enrollees with chronic conditions
• Allows a free annual Medicare well visit with assessments and individualized prevention plan

• Eliminates Medicare Part D (drug coverage) co-pays for dual eligibles receiving waiver services
• Improves Medicare Part D access to key anti-seizure, anti-anxiety and anti-spasm medications

Selected Prevention, Provider Training, Data Collection and Accessibility Issues Addressed by the ACA

• Eliminates co-pays for critical prevention services
• Creates the Prevention and Public Health Fund (PPHF) to provide new funding for transformational investments in promoting wellness, preventing disease, and other public health priorities

• Increases opportunities for training of health care providers (including dentists) on the needs of persons with developmental and other disabilities
• Authorizes new training programs for direct support workers who provide long term services and supports
• Improves data collection on where people with disabilities access health services and where accessible facilities can be found

• Adds disability as a category to measure health disparities and in health care quality reporting surveys
• Requires the establishment of criteria for accessible medical diagnostic equipment

Key Disability Data Regarding Access to Health Care

According to the Centers on Medicare and Medicaid Services (CMS):

• 15% of the uninsured have at least one disability (HHS/ASPE Analysis of 2010 CPS self-reported data)
• 12% of uninsured adults with incomes below 138% of the federal poverty level report limited ability to work or unable to work (Urban Institute Analysis of 2006 MEPS data)

Altman, B. Bernstein A. Disability and health in the United States, 2001-2005. Hyattsville, MD National Center for Health Statistics 2008

• Adults 18-64 with cognitive difficulty, 13.6 % had no insurance, 32.1% private insurance, 41.0% Medicaid, and 27.0% Medicare.
• Adults 18-64 with disabilities are less likely than those without disabilities to have private health insurance coverage – 46.3% for those with complex activity limitation and 61.3% with basic actions difficulty (61.3%) compared to 75.2% with no disability.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Children with Special Health Care Needs in Context: A Portrait of States and the Nation 2007. Rockville, MD: U.S. Department of Health and Human Services 2011.

• Children with special health care needs – 29. 4% had inadequate coverage compared to 22.1% of children without special health care needs. Inadequate insurance is a far more prevalent problem than gaps in insurance or lack of insurance among children with special health care needs. (29.4% inadequate insurance whereas 12.3% had gaps in insurance or no insurance).
• Children with special health care needs have unmet needs for specialty medical care—27% had problems accessing specialists and of the children with emotional, behavioral or developmental conditions, 48.4% did not receive mental health services.

Children with special health care needs are defined in the National Survey of Children’s Health as those who have one or more chronic physical, developmental, behavioral or emotional conditions for which they require an above routine type or amount of health and related services. 14-19% of children in the U.S. meet this need.