Life with MS

Health Insurance for People with MS, 2019

By Greg LaFleur

Do you need new health insurance coverage for 2019? As open enrollment periods for Federal programs draw near, there is information you need to know about insurance through the Affordable Care Act and Medicare.
The Affordable Care Act, past and present

In March 2010, President Barack Obama signed the Affordable Care Act into law. The law really began affecting the U.S. population in 2014, when many of the Affordable Care Act’s provisions first took effect. People with insurance experienced changes to their insurance plans with the implementation of “essential health benefits” and free preventative exams. Another significant change was that pre-existing conditions no longer prevented people from getting insurance policies.  
Those without insurance were encouraged to purchase insurance on one of the several marketplaces, run by their individual state or federal government. There were penalties that were applied to your Federal income tax if you could not prove you had medical insurance, either from an employer, marketplace, or an individual policy. Under the ACA, depending on your level of household income, you could be eligible for money to help pay for your medical insurance premiums, or you must have been exempt from the tax penalty.
Since the introduction of the ACA, there has been a great deal of debate about the act, and some significant changes have been made. Although the Affordable Care Act has continued to evolve since 2014, the pace of change has slowed and it has encouraged everyone seek out the proper medical insurance coverage for themselves and their family.  
What stays the same

Because of the Affordable Care Act, all insurance plans, including Medicare, must cover preventative doctor visits. Additionally all policies must include or cover these essential health benefits:

  1. Outpatient care from a hospital
  2. Emergency room coverage
  3. Inpatient care, while in hospital
  4. Care before and after the birth of a child
  5. Pediatric services
  6. Mental health and substance abuse
  7. Prescription drug coverage
  8. Lab tests
  9. Preventative services; screenings and vaccinations
  10. Devices and services to help you recover from an injury

Another result of the Affordable Care Act are premium subsidies. If you meet certain income criteria, you may qualify for help to pay for medical insurance through the insurance marketplace.
What has changed

• The tax penalty for the “Individual Mandate” was essentially eliminated by zeroing out the amount of the penalty. Previously, if you did not have health insurance, then you were assessed a fine anywhere from $695 - $2,085 (in 2017). For 2018, the penalty was set to $0 and therefore will not have any effect on anyone without medical insurance.

• An individual cannot be discriminated against or refused coverage because of a pre-existing condition such as MS. However, you might experience a waiting period of up to 12 months for coverage of that condition when enrolling in a medical insurance plan for the first time. If you currently or previously had coverage on a qualified medical plan, you can provide proof of coverage by requesting a Certificate of Coverage from your current or prior insurance carrier.

• For certain employers, enforcements have set in and some employers are facing fines for not complying with the law. Affordable Care Act provisions, like the Employer Mandate, Employer Reporting Requirements, and Affordability Requirements remain the same, but certain provisions are only now being enforced. 
Where to go if you are not insured

You have three options:

1.) Get a medical insurance plan through the marketplace. Whether you use your state marketplace or the federal marketplace depends on what state you live in. The 2019 enrollment period runs from Nov. 1 to Dec. 15, 2018. If you miss the Dec. 15 deadline, you cannot get insurance for 2019 unless you qualify for a Special Enrollment Period.

2.) Contact a qualified insurance agent that sells individual plans.

3.) If you are eligible, you can go through Medicare. Keep in mind, there are some qualifying criteria, especially if you are under age 65. For example, if you are permanently disabled, and you have received Social Security disability benefits for 24 months, then the Social Security Administration may determine that you are eligible. Medicare open enrollment is Oct. 15 to Dec. 7, 2018.

Prescription coverage

If you have medical insurance, chances are your insurance plan covers a portion of the cost of MS drugs. Through a cost share arrangement, typically after you pay a copay, your insurance plan will cover the majority of the cost of your prescription. If you are changing insurance, it is highly advisable that you talk to your insurance carrier in advance to confirm they will cover the prescription that your doctor prescribes.