The Affordable Care Act: Key Provisions for People With Arthritis

What does the law mean for coverage and costs?

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arthritis foundation helpline tile promo

The Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010. There are services and savings available for people living with osteoarthritis, rheumatoid arthritis and other types of arthritis that are in effect now, and others will be implemented in coming years. Here is an overview of how it affects your costs and coverage.

You can’t be denied – or dropped – because of your arthritis. Under the ACA, you can’t be refused coverage, be charged higher premiums or get dropped from coverage because of your arthritis.

You can comparison shop for insurance. If you are uninsured or under-insured, you can shop around on the Health Insurance marketplace at The plans are broken into four categories:

• Bronze
• Silver
• Gold
• Platinum

Gold and platinum plans have higher monthly premiums, but you’ll pay lower out-of-pocket costs. That could save you money if you’re paying for several arthritis medicines and rheumatologist visits. You can search and compare details on monthly premiums, annual deductibles and types of services covered. Open enrollment will run from October 1, 2013, to March 31, 2014. Coverage will start January 1, 2014.

You can’t max out your health coverage. In the past, some insurance companies limited how much they would pay for coverage over a person’s lifetime.  That amount could be up to a $1 million or higher. A million dollars might seem like a lot of money, until you consider that a single hip replacement surgery can cost $100,000 and biologic drugs can exceed $2,500 per month. In 2014, insurance companies can’t impose lifetime limits on coverage.

You’ll pay lower out-of-pocket costs. Starting in 2014, annual out-of-pocket costs for your medical visits and prescription drugs will be limited to $6,350 (the maximum cost for a family will be $12,700).

Your premium payments must largely go to your care. The government requires insurers to spend at least 80 percent of premium payments on medical care. If they don’t hit 80 percent, you get a rebate or a reduction in future premium payments.

You’ll have access to essential health benefits. Both employer-sponsored health insurance plans and plans offered in the marketplace must cover a list of essential health benefits. These include hospitalization for surgery, prescription drugs, and the management of chronic diseases like arthritis.  If you’re on Medicare or have a new private plan, co-payments and deductibles for preventive care are eliminated. In 2018, this requirement applies to all plans.

If you’re on Medicare, your drug costs will go down. Medicare Part D drug coverage includes a “donut hole” that kicks in once your drug costs reach $2,970. Then you pay the difference until you hit the out-of-pocket spending limit of $4,750. If you’re on biologic drugs, which can cost upwards of $30,000 a year, you’ll get to that donut hole pretty quickly. Under the ACA, as soon as you fall into the donut hole, you’ll get a 50 percent discount on brand-name drugs. The discount will continue to increase until it reaches 75 percent by 2020.

You’ll get access to cheaper biologic drugs. The ACA has paved the way for biosimilar versions of biologics to reach the market more quickly. Biosimilars slow the progression of joint damage just like biologics, but they’re cheaper. Medicare will reimburse for biological and biosimilars in the same way.

You can appeal rejected claims. When your health insurer refuses to pay a claim, now you can appeal the decision. If your insurer still says “no,” you can have the decision reviewed by an independent organization. And you can get help with those appeals, as well as with complaints, through consumer assistance programs the ACA is helping states establish. (For a state-by-state listing of these programs, visit:

Your child can stay on your plan until age 26. That’s good news for parents of the nearly 300,000 kids with juvenile arthritis. And even when your young adult needs to find insurance coverage, he or she can’t be denied or discriminated against because of JA.

For more on the ACA and what it will mean for you, visit:

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