This week, I am answering questions from readers about provisions in the Affordable Care Act related to drugs and medical-care coverage under Medicare and high-risk insurance plans.
Q. I have a friend who is due to have a knee replacement soon. Her doctor told her it is good she is doing it now because she is over 70. “Obamacare” won’t pay for surgery for people after 70. Is this true?
A. It’s not true.
“There is no provision in the health-care law that makes changes in Medicare benefits based on age,” says Juliette Cubanski, associate director of the Medicare Policy Program at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
There has been a great deal of discussion about whether the Affordable Care Act will result in rationing of seniors’ care. Much of this has centered on the Independent Payment Advisory Board, which was authorized to help control the growth in Medicare costs. Starting in 2014, the IPAB will make recommendations to lower costs if Medicare spending exceeds established targets. Proposed changes must be considered by Congress and implemented by the administration within designated timeframes.
The IPAB is prohibited from rationing care, from making decisions about what benefits will or won’t be covered, and from increasing beneficiaries’ premiums or cost sharing, says Cubanski. It could recommend reducing payments to certain providers and service suppliers, however.
Q. I heard that some people will only be allowed four prescriptions under the Affordable Care Act. Is this true? Is this the rule for seniors?
A. There are no provisions in the Affordable Care Act that limit the number of drugs that can be covered, either in private plans or the Medicare program, say experts.
Medicare Part D prescription drug plans vary widely, both in terms of which drugs are covered and in how much beneficiaries must pay out of pocket for them. But Medicare drug plans must cover at least two drugs in each drug class or category, such as cardiovascular agents, which would include cholesterol-lowering medications, and blood- glucose regulators such as oral anti-diabetes drugs. In addition, the plans must cover nearly all the drugs in six protected classes, including cancer drugs, HIV/AIDS drugs, antidepressants, antipsychotics, anticonvulsants and immunosuppressant drugs.
Although plans may cover a wide range of drugs, they may restrict access by, for example, limiting how often a beneficiary can fill a particular prescription or requiring beneficiaries to try a generic version of a drug before approving the brand-name drug.
In 2013, the average Medicare prescription drug plan will cover 1,413 drugs, according to Avalere Health, a research and consulting firm in Washington.
Q. My 52-year-old son is covered by the West Virginia high-risk insurance plan. I live in Florida and am his caregiver. I need to move him here. Can his high-risk insurance be transferred to Florida without having to wait six months?
A. It depends. In most states, there are two high-risk insurance programs that provide coverage for people with serious illnesses who are unable to find private insurance. The six-month waiting period you refer to before he qualifies for Florida coverage could be a factor in some instances.
The Affordable Care Act created a temporary Pre-Existing Condition Insurance Plan (PCIP) program in every state and the District. These plans provide comprehensive benefits, and premiums can’t be more expensive for people with medical problems. But applicants have to have been uninsured for six months in order to qualify for a PCIP.
The program will be discontinued in 2014 when insurers will no longer be able to turn applicants down for coverage because of preexisting medical conditions.
In addition, 35 states operate high-risk insurance pools that also serve people who can’t get coverage elsewhere. These plans may be pricier and the coverage may be less comprehensive than that available through the PCIPs.
If your son is enrolled in the West Virginia PCIP, he can transfer to the Florida PCIP immediately, says Jean Hall, director of the Institute for Health and Disability Policy Studies at the University of Kansas. Transfers between PCIPs don’t require another waiting period.
However, if your son is enrolled in West Virginia’s regular high-risk pool, he can’t transfer to the Florida high-risk pool because it’s closed to new enrollment. He can transfer to the Florida PCIP, but he’d first have to go without insurance for six months.
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