By Bernard A. Krooks
In light of the recent Supreme Court decision, the merits of the Affordable Care Act (ACA) are subject to much debate. While experts continue to analyze its thousands of pages, the ACA clearly has the potential to benefit both seniors and individuals with disabilities.
As of 2014, private insurers may not deny coverage or charge premium rates based on pre-existing conditions (they”™re already forbidden to do so for anyone under 19). Limits on lifetime coverage will be eliminated. This opens opportunities to middle-class families whose incomes render them ineligible for Medicaid coverage of loved ones with disabilities. It also benefits seniors who are supplementing Medicare with private coverage through their retirement plans. In addition, private insurers must offer a menu of “essential benefits,” including mental health services, speech, occupational and physical therapy, and ABA, a popular treatment for autism. But families should watch for the fine print. Insurers will likely question the medical necessity of specific services and will place limits on the number of covered sessions.
ACA gives states the option of expanding Medicaid coverage to persons earning up to 133 percent of the federal poverty level ($14,856 for an individual). This is particularly important to families with special needs because Medicaid pays for many critically important services, including community-based housing. The federal government will pay 100 percent of the increased cost for three years, gradually lowering its participation to 90 percent by 2020. Gov. Andrew Cuomo has announced plans to implement the expansion, but other state governments are wavering. In states that decline to participate, adults earning too much for Medicaid but too little to qualify for tax subsidies will remain uninsured.
Community-based services
More than 70 percent of all nursing home residents depend on Medicaid. Now, ACA”™s Money Follows the Person and the Community First Option will allow them to be cared for in other settings without jeopardizing that funding. Because Medicaid is a means-tested program, there have long been protections for certain assets held by the “well” spouse when an individual entered a care facility. Now those protections will be extended to community-based situations. While New York has an excellent record of exploring alternatives to institutional care, these new programs will make an even wider range of choices available to seniors and individuals with disabilities.
Improvements to Medicare
There are also important implications for Medicare. Perhaps most apparent is the closing of the infamous prescription drug “donut hole,” which affects 25 percent of all beneficiaries. This refers to the fact that Medicare Part D provides coverage up to a specific dollar limit, after which individuals must pay all drug costs until they reach a “catastrophic” threshold. ACA requires pharmaceutical companies to reduce both brand name and generic drug prices for Medicare enrollees caught in the “donut hole.” Brand name prescription prices are currently reduced by 50 percent, with discounts gradually increasing to 75 percent in 2020.
Protections are also increased for individuals opting for Medicare Advantage plans, which now must hold co-pays for chemotherapy and dialysis to levels at or below those required by Medicare A and B.
Better care and safety
A number of ACA-funded studies will seek to improve care and lower costs. The Independence at Home Demonstration is a three-year trial that offers home-based primary care to chronically ill individuals. The goal is for physicians and nurse practitioners to devote more time to patients and to be more accountable for overall outcomes.
Today, nearly 20 percent of the Medicare patients discharged by a hospital are readmitted within 30 days, but ACA”™s Community-Based Transitions Program will strive to lower those numbers, including reductions in hospital-acquired infections.
ACA also includes initiatives to increase the safety of seniors and individuals with disabilities. The Elder Justice Act, Nursing Home Transparency and Improvement Act, and Patient Safety and Abuse Prevention Act seek to prevent and prosecute instances of abuse and to provide better information concerning the quality of institutional care.
These initiatives hold much promise for strengthening Medicare and improving the availability of health services to individuals with disabilities. But their ultimate effectiveness will be determined by the countless details needed to move from vision to reality.
Bernard A. Krooks, founding partner of Littman Krooks L.L.P., with offices in White Plains, Manhattan and Fishkill, is former president of both the National Academy of Elder Law Attorneys and the Special Needs Alliance. Visit the firm”™s website at littmankrooks.com.
