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THIS WAY IN: How Does Health Care Reform Impact You?

Wesolowski, Kierstin

doi: 10.1097/01.NNN.0000389991.34549.e0
Departments: the Waiting Room

On March 23, 2010, following months of contentious debate on Capitol Hill, President Barack Obama signed the Patient Protection and Affordable Care Act (H.R. 3590)—otherwise known as the health care reform bill—into law, decisively altering the United States health care system. Just seven days later, he signed the Health Care and Education Reconciliation Act (H.R. 4872) into law, adding revenue and financing changes to the historic legislation.

As a result of the health care reform bill, “it's estimated that an additional 32 million Americans will [have health insurance] by 2019,” says Amy Kaloides, advocacy senior manager for the American Academy of Neurology (AAN). “Some patients previously excluded from being covered due to a pre-existing condition, employment situation, or cost will find new health insurance exchanges and tax deductions to gain them coverage.” People with chronic diseases will also have an easier time accessing coverage and keeping it once they're insured.

The state-based health insurance exchanges will be run by either government agencies or non-profit organizations, and will provide a way for individuals or small businesses (fewer than 100 employees) to purchase health insurance, says Kaloides. The exchanges will eventually offer comparisons of insurance plans (including services covered, premiums, deductibles, and out-of-pocket expenses) to create competitive prices among insurance companies, she notes.



It's been six months since the reform bill became law, yet many Americans remain unsure of how it will fundamentally alter the old health care system—and, more importantly, how these changes will impact them personally.

“I think it's safe to say there has been and will continue to be confusion over what is in the new law and the effect it will have [on patients],” says Kaloides. “Many provisions take effect over time,” leaving people unsure of exactly when they will be implemented.

“The most frequently asked question [we receive] is ‘when are these provisions going into effect?'” says Robert Egge, vice president of the Alzheimer's Association's Public Policy and Advocacy Division. “Underlying this question is the patient's concern over whether their problems will be addressed when they go to the doctor.”

To make understanding health care reform easier, the AAN has explained five major provisions of the law—including when they will take effect—pertinent to people with neurologic conditions.

Insurance Rejection Due to Pre-existing Conditions Effective September 2010, children with a pre-existing condition, such as epilepsy, attention-deficit hyperactivity disorder (ADHD), or cerebral palsy, can no longer be denied coverage on their parent's health insurance plan. In addition, insurance companies will no longer have the ability to insure a child but refuse to pay for treatments for that child's pre-existing condition.

Adults won't receive this coverage until 2014. In the meantime, adults who have been uninsured for six months and have a pre-existing condition will be entered into a new program known as the “high-risk pool.” This program will provide adults with affordable insurance until 2014, when it will be illegal for insurance companies to deny coverage to adults with a pre-existing condition as well.

Dropped Insurance Coverage Everyone's worst fear is having their insurance coverage dropped when they get sick—especially people with neurologic diseases. “The community we have heard from the most is patients with early-onset Alzheimer's disease, who live day-to-day with concerns and fears about [retaining] their health insurance,” says Egge. However, effective September 2010, it will be illegal for insurance companies to drop people from their coverage when they become ill. This applies to all new and existing insurance plans.

“The provision makes it easier for people with early-onset Alzheimer's disease to retain insurance coverage,” says Egge. “This is especially important because they may suffer from poor job performance due to their disease and often lose their jobs. And of course, prior to the reform, they had difficulty obtaining other insurance.”

Lifetime and Restrictive Annual Limits In September, insurance companies will no longer be able to place lifetime limits on coverage costs. This provision is important to any patient with a chronic neurologic condition, according to Elaine C. Jones, M.D., a neurologist with Southern New England Neurology in Bristol, RI. Chronic conditions such as multiple sclerosis, Parkinson's disease, or Alzheimer's disease require ongoing treatment. It's imperative that these patients retain their health insurance coverage in order to continue seeing their neurologist, in addition to alleviating some of the cost of their care, says Dr. Jones.

The use of annual limits will also be greatly restricted in all new plans and grandfathered group health plans. In 2014 any use of annual limits will be illegal.

Increased Transparency Required of Insurance Companies “Another change from the current system will be increased transparency,” says Kaloides. Patients will gain access to more information on their health care providers and centers as well as the cost and quality of the care they receive.

“Although the specifics of the transparency requirements are still being determined, within the next four years patients will have access to more information on the quality, safety, and cost for procedures, hospitals, and physicians—available online,” says Kaloides. “In addition, the U.S. Department of Health and Human Services will issue regulations to specify the format for improved public reporting. Some agencies, such as the Centers of Medicare and Medicaid Services, have already started posting some of this information on its Web site.”

The first step in this process occurred on July 1, 2010, when patients were given access to a Web site designed to help consumers decide which insurance plan is best for them. Visit the Web site at

Closing the “Donut Hole” Coverage for prescription drug benefits under Medicare will also change under the new law. In 2006, a prescription medication benefit was added to Medicare, but it included a gap in coverage that is commonly referred to as the “donut hole.” After patients reach their $310 deductible, those who are not low-income or do not have supplemental insurance must pay 25 percent of the total cost of their prescriptions out-of-pocket until it amounts to $2,830. At that point, patients must pay 100 percent of their prescription medication costs until it reaches $6,440—this being the donut hole. And a patient's total prescription medication costs reset every calendar year.

On average, patients spend $340 per month or $4,080 per year on prescription medications as a result of the coverage gap, according to the Office of the Actuary of the Centers for Medicare and Medicaid Services. But, according to Kaloides, “the Medicare Part D ‘donut hole' is on its way to being phased out. Since neurologic drugs are often expensive, this is a definite win for patients.”

The formula for reimbursement will change under the new law, but in the interim patients who reach the coverage gap in 2010 will be eligible for a $250 rebate. Those who reach the threshold in 2011 will receive a 50 percent discount on prescription drugs. Patients do not have to fill out an application to be eligible for the rebate—it will be mailed directly from Medicare.

Looking Forward “The best resource for patients with neurologic disease about the new law will probably be their local or national support groups,” says Kaloides. (See Resource Central, page 42, for a list of patient advocacy organizations.) “Changes in the Medicare and Medicaid programs will likely be communicated in the new educational materials by the Centers for Medicare and Medicaid Services.”

Keep reading each issue of Neurology Now for continuing coverage on health care reform and how it impacts people with neurologic conditions and caregivers.

—Kierstin Wesolowski

©2010 American Academy of Neurology