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This Way In: Puzzling Out the Affordable Care Act

Collier, Andrea King

doi: 10.1097/
Departments: The Waiting Room


The Patient Protection and Affordable Care Act, signed into law in March of 2010, promised to address the needs of the uninsured and those who struggle to maintain insurance and manage the costs of chronic illnesses such as multiple sclerosis (MS), neuropathy, and Parkinson's disease. Because some provisions won't roll out until 2014 and beyond, Neurology Now is providing ongoing coverage of the law (for the first article in the series, “How Does Health Care Reform Impact You?” visit

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One of the first provisions to kick into effect was protection for children up to age 19 who have a pre-existing condition. As of 2010, they can no longer be denied coverage under their parent's insurance plan. The Act also prohibits insurance companies from insuring the child but denying claims for treatments for his or her pre-existing conditions.

The Act also extends parents' ability to keep their young adult children covered under their private health insurance policy until the age of 26. Without this provision, thousands of young people in college and entering the workforce would find themselves uninsured—and with a pre-existing condition, often uninsurable.

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If you're already on Medicare, you won't see a reduction in benefits for Part A (hospital and inpatient care) or Part B (medical services such as doctor visits and outpatient care). In fact, you'll see new wellness and prevention benefits. Starting in January 2011, co-pays and deductibles for preventative care were eliminated. Medicare will also now cover a free annual physical for all enrollees.

Where you may see some changes in coverage is if you are one of the 11 million members of a Medicare Advantage plan also known as Medicare Part C (plans such as HMOs and PPOs offered by insurance providers approved by Medicare). It is anticipated that federal reimbursements will be reduced in these plans, according to AARP Legislative Policy Director David Certner.

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The Department of Health and Human Services (HHS) is still defining what essential benefits will be required to be covered by all plans. The final word on this may not happen until 2014; so far, it is projected to include wellness services, outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drugs, lab fees, pediatric services including oral and vision care, and chronic disease management. Advocates for people with neurologic illness such as MS anticipate that rehabilitation services will also be included.

While many health care advocates are pleased with the increase in services, not all states are. Opponents cite the financial impact of implementation at the state level and the constitutionality of the law. In fact, 26 states came together to file suit to challenge its constitutionality and stop implementation. Several other states have also tested the law in federal courts.

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The Community Living Assistance Services and Support Act (CLASS) and the Community Choice Act—both part of the Affordable Care Act—will provide a voluntary long-term care insurance program no matter what a person's condition. Advocates see this as a win for people living with chronic and progressive illnesses that may call for long-term care.

The CLASS Act became effective earlier this year, but benefits will be further defined by HHS in October of 2012. New voluntary enrollment will take place shortly after. For an estimated $123 per month premium paid by individuals, CLASS will provide eligible enrollees approximately $50 per day to purchase non-medical support services such as home health care, assistive technology, transportation, home modification, and adult day care to maintain the ability to live in the community. Eligible individuals may also be able to use the cash for assisted living or nursing home residence.

The Community Choice Act supports home and community-based services specifically for Medicaid recipients who require long-term care. In February of this year, HHS announced the availability of $4.3 billion in new funding to help support community-based alternatives to long-term care. Like many provisions in the new law, this change will not take effect immediately. Neither plan pays out benefits until 2017, leaving many people who need long-term care without affordable coverage until then.

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While the Affordable Care Act has the potential to offer specialized care for more people who need it because of their chronic illness, the neurologists who manage that care may be left out in the cold.

The new law stipulates a 10-percent bonus payment for Medicare physicians who provide substantial amounts of evaluation and management services (face-to-face care for patients). As important providers of this type of care, neurologists were overlooked for the bonus. In addition, the Centers for Medicare and Medicaid Services discontinued payment for consultation services in 2010. As a result, neurologist reimbursement is suffering.

Neurologists are working to introduce an amendment to the health care bill that would include them as eligible for the 10-percent bonus payment. They are also working with other specialties affected by the loss of payment for consultation services to ask Congress to have those payments reinstated.

Ensuring fair and appropriate reimbursement for the work of neurologists is critical in making sure patients have access to well-trained specialists. According to the American Medical Association, cuts in an already strapped reimbursement system could cause physicians, including neurologists, to take fewer new Medicare patients. A study released by the American Association of Neurological Surgeons reports that 65 percent of its 3,400 member are now referring their Medicare patients to other practices to reduce the reimbursement burden.

The American Academy of Neurology (AAN) adds that cuts in reimbursement rates may make neurology a less attractive specialty for medical students, deepening the shortages of neurologists around the country. According to the AAN, there is currently one neurologist for every 18,000 Americans. They estimate that if the reimbursement rates continue, that gap will grow to one in 21,000 by 2020. This shortage can have a major impact on the availability of care needed by patients.

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The Affordable Care Act can be difficult to puzzle out. Fortunately, the legislation has also increased the level of transparency for patients trying to navigate the system. One of the most easily accessible tools available for people trying to understand the ins and outs of the Affordable Care Act—including what goes into effect when—can be found at Many agencies, such as the Centers for Medicare and Medicaid Services ( are adding information on health care reform to their Web sites. The government is also using social media tools such as Facebook ( and Twitter ( to help people get the latest information as it becomes available.

© 2011 American Academy of Neurology