The Affordable Care Act’s Senior Care Benefits: Dealing With Chronic Diseases

While there are many changes wrought by the Affordable Care Act, they are not all senior-care-specific. For example, one of the most popular requires insurers to cover consumers with pre-existing conditions. A surprising amount of senior citizens are burdened with chronic diseases (about 80%), so these changes benefit quite a few seniors.

Doing Away with Pre-Existing Conditions
As of January 1st, 2014, the concept of ‘pre-existing conditions’ has been done away with, as per the ACA’s regulations. Any chronic disease, before that date, could (and almost always would) be classified as a ‘pre-existing condition,’ meaning that the insurance company would either deny you coverage for anything related to that disease or would charge you dramatically more in premiums because of that disease.

With that ability gone, having a chronic disease no longer puts you on the insurance blacklist, and it no longer means you have to pay out the nose for your health insurance forever — a huge benefit to most seniors.

Generic Biologic Drugs
Before the ACA, there was a class of drugs called ‘biologic medicines’ that are created using microorganisms vs. using chemical processes. They were particularly good for treating autoimmune disorders, most of which are chronic diseases. The problem was that there was no legal way for a company to ever make a generic biologic medicine. The process, not the molecule, was patented, and there was no way to know you were replicating the process accurately because biologic medicines are dramatically more complex than chemical ones.

The ACA rules are that a company wanting to sell a biologic medicine must share the process that created it, starting 12 years after they begin selling (which thus allows competitors to make a generic of the same medicine.) This benefit obviously won’t be seen until around 2020, but at that point, many expensive and unique medicines will become much more available to chronic disease sufferers.

Limits on Out-of-Pocket Medical Expenses
Up until January 1st, 2015, the standard among the insurance industry was that your deductibles and co-pays were unlimited. For example, if you racked up $80,000 in bills with a 15% co-pay, you were on the hook for $12,000. That is a hefty sum, but it’s actually something that many pre-existing conditions could easily lead you to pay.

Today, your deductible + co-pay out-of-pocket expense is limited to $6,300 per individual or $12,700 per family each year. Still quite a bit, but a huge boon for people with chronic diseases that cause regular large medical bills.

Un-limits Lifetime/Annual Caps on Coverage
The last massive problem with having a chronic disease was the tendency of insurance policies to have coverage limits; they would each simply stop paying for your chronic disease at a certain point, and everything left was out-of-pocket. While the ACA still leaves insurance companies the leeway to stop paying for most expenses when the coverage limit is reached, certain ‘essential health benefits’ — among them prescription drugs, hospital stays, and chronic disease treatment — cannot be capped.

In short, if you have a chronic disease — which means four out of five people who qualify for senior care in the first place — the ACA has been a Godsend.


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