MS and Affordable Care Act
Reviewed by: HU Medical Review Board | Last reviewed: May 2015. | Last updated: December 2020
The Patient Protection and Affordable Care Act (commonly called the Affordable Care Act or ACA) was passed by Congress and then signed into law by President Obama on March 23, 2010. Following a well-publicized lawsuit, on June 28, 2012, the Supreme court rendered a final decision to uphold the law. Starting in 2010 and continuing over the following 10 years, a series of reforms are to be implemented within the US healthcare system, primarily affecting federal and state laws and regulations which control health insurance and the delivery of care
How will the Affordable Care Act affect me if I have MS?
The Affordable Care Act (ACA) has many provisions which protect persons with disabilities and those diagnosed with diseases such as MS. Under the new law, insurance companies can no longer discriminate against persons with pre-existing conditions (including disability) for all employer-based and new individual plans starting in 2014. Insurance companies can no longer impose lifetime dollar limits on coverage, and most annual limits will be restricted (except for in some individual policies which were already in existence at the time the law was passed).
Controversy has surrounded the ACA (also called “Obamacare”) and with so many changes being implemented at the state and national level, it is challenging to know how the law will affect YOU personally. It is important to get the facts about what the new law means to you now and in the future.
Important sources for the latest information on the Affordable Care Act (ACA), and how it may affect you, are available online.
The US Department of Health and Human Services website, Healthcare.gov, provides several useful consumer tools regarding the new law, including highlights of key features of the ACA and the complete text, a timeline of what and when parts of the law are scheduled to come into effect, information on how the law is being implemented on a state-by-state basis, and a list of resources to learn more about the ACA and get answers to your questions.
Before the ACA, health insurance companies could offer limited coverage plans in the individual and small group markets which did not include the same essential health benefits (EHB) offered by typical employer-based group coverage. The ACA requires that all health plans offer a comprehensive package of essential benefits within the following 10 categories: outpatient care, hospitalization, emergency care, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory services, rehabilitation services and devices, preventative and wellness services and chronic disease management, and pediatric services, including dental and vision care.
Is MS a pre-existing condition, and how does that affect my eligibility for coverage?
For the purposes of health insurance coverage, a pre-existing condition is defined as:
- “Any physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period prior to the enrollment date.”
When fully phased-in, the ACA will prohibit health insurers from denying coverage to any person on the basis of a pre-existing condition. Most persons with MS who enroll in a health insurance plan will have received some medical care for their MS within the 6-month period before enrollment.
Therefore, until the relevant provision is implemented in 2014, applicants with MS could be denied coverage. In the interim, the ACA has established the pre-existing condition insurance plan (PCIP) to provide coverage to those who have been denied. To qualify for PCIP, you must have a pre-existing condition, be a US citizen, and have been without health insurance coverage for at least the 6 months prior to applying. You are not eligible for PCIP if you have health insurance coverage of any kind. Program requirements vary by state and you can learn more at Healthcare.gov or by calling the National MS Society at 1-800-344-4567.