[NYAPRS Enews] Impact of Health Care Reform on People with Disabilities

[Harvey Rosenthal]

Impact of Health Care Reform on People with Disabilities          April
27, 2010

Peggy Hathaway, Vice-President for Public Policy, and Andrew Morris,
Director of Legislation, for Spinal Cord Advocates, a public policy
collaborative of United Spinal Association and the National Spinal Cord
Injury Association, and Barbara L. Kornblau, JD, OTR, Dean, University
of Michigan - Flint, School of Health Professions and Studies, on behalf
of the American Association of People with Disabilities (AAPD). 

 

Introduction

The disability community has worked together tirelessly for more than a
year to achieve health care reform. After health care reform nearly died
several times, Congress revived it and it became law in March 2010. 

>From any perspective, the final legislation is not perfect, but it will
bring important improvements in health care coverage for people with
spinal cord injuries and disorders and people with disabilities in
general. The insurance market reforms alone are clearly beneficial. Once
the permanent provisions go into effect, no longer will health insurers
be able to deny coverage, charge outrageous premiums, offer less
coverage to people with pre-existing conditions or impose annual or
lifetime caps on benefits. In addition, the bill enacts several
provisions that encourage home and community based services so that
people with disabilities do not have to choose between living at home
and getting the services they need. 

As of 2014, when many permanent provisions go into effect, states must
have health insurance exchanges (or alternatives) through which people
and some employers may purchase health insurance. In addition, most
people will be required to have health insurance unless they are
eligible for health care through government programs such as Medicare,
Medicaid, Department of Veterans Affairs and military service.
Multistate plans are allowed but individual states can require
additional benefits to be covered by health insurance in their states.
There will be refundable tax credits for some people based on income and
tax credits for some small businesses that provide health insurance to
their employees. 

Summarized below are major final health care reform provisions that
particularly impact people with disabilities. This list is by no means
exhaustive. The final legislation not only reforms health insurance but
also addresses many health care issues including prevention and wellness
and improving the health care workforce. 

With enactment of the law, reform is only beginning. The disability
community must stay involved and present as implementing regulations are
drafted, proposed, promulgated, and implemented. For the foreseeable
future, we will need to be vigilant in making our voices heard 2 

with regard to the countless rules and regulations to be issued,
advisory boards and commissions to be established, and many other steps
to be taken to implement health care reform. 

Find more information on our public policy website
www.spinalcordadvocates.org or contact our Washington, DC public policy
staff Peggy Hathaway and Andrew Morris at 202-556-2076,
phathaway at unitedspinal.org or amorris at unitedspinal.org. 

 

Insurance Market Reforms 

Generally, health care reform legislation includes many provisions that
make private market health insurance far more available and affordable
to people with disabilities and other chronic conditions. 

 

No Discrimination Based on Pre-Existing Conditions 

As of 2014 health insurers will no longer be able to discriminate
against people due to disabilities or other pre-existing conditions.
Health insurers will no longer be allowed to deny coverage, charge
higher premiums, exclude benefits relating to pre-existing conditions,
rescind coverage after someone is injured or acquires a new condition,
or impose annual caps on benefits. Most of these provisions go into
effect for children in September 2010. 

 

Lifetime and Annual Benefits Caps 

Lifetime caps on benefits are prohibited immediately. This will end the
common insurance practice of imposing lifetime caps such as $1 million.
Between now and 2014, the Secretary of Health and Human Services (HHS)
may restrict annual caps on benefits. As of 2014, both lifetime and
annual caps on benefits are prohibited. 

 

Temporary High-Risk Pools 

Between now and 2014, many people with pre-existing conditions are
eligible to purchase coverage through high risk pools. 

Unfortunately, to be eligible to purchase this insurance, people must
have been without any health coverage whatsoever for at least six
months. Also, the insurance could be unaffordable for many people.
Premiums are subject to restrictions, but even so, the law allows
insurers to charge older people four times as much as younger people.
Limits on 3 

out-of-pocket expenses must be consistent with high-deductible health
savings account plans-currently $5,950 for an individual and $11,900 for
a family. 

It is currently uncertain when the temporary high risk pools will become
available or where people will apply for insurance in these pools. If a
state does not offer the required insurance, HHS will either help
establish a pool in that state or residents of that state will be
eligible for a national high risk pool. This decision-making process is
now underway. 

 

Mandatory Health Plan Coverage Provisions

 

Essential Benefits 

For most health insurance plans (including plans offered in the
exchanges and individual and small group plans but excluding
grand-fathered individual and employer-sponsored plans) the law mandates
coverage of at least the following essential benefits: ambulatory
patient services, emergency services, hospitalization, maternity and
newborn care, mental health and substance use disorder services
(including behavioral health treatment), prescription drugs,
rehabilitative and habilitative services and devices, laboratory
services, preventive and wellness services and chronic disease
management, and pediatric services including oral and vision care. 

HHS has the authority to further define essential benefits consistent
with these required elements and is expected to do so. If HHS adds
essential benefits, the law requires HHS to take into account the health
care needs of people with disabilities and other diverse groups. We will
continue to make our voices heard as HHS goes through the process of
defining essential benefits. 

For people with disabilities, it is a substantial improvement that
rehabilitation and habilitation services are essential services. Many
people with disabilities depend on them (e.g. to maintain muscle bulk
and minimize spasticity) but pre-health care reform insurance policies
did not cover them or severely limited the number of treatments. 

As we understand it, the term "devices" is meant to include all durable
medical equipment (including wheelchairs), prosthetics, orthotics and
supplies (DMEPOS). This provision would be stronger if it made this
point more explicitly. Because DMEPOS are critically important to many
people with disabilities, we are advocating that anticipated HHS
regulations defining essential benefits will explicitly provide that all
DMEPOS are included in the meaning of "devices" as essential medical
benefits. 

It is important that mental health and substance abuse services are
included as essential benefits. 

 

Limits on Cost Sharing 

The amount that people will have to pay out-of-pocket cannot be greater
than the limits for health savings accounts. Small group market plans
are prohibited from deductibles greater than $2,000 for individuals and
$4,000 for families. These maximums may 4 

increase only in accordance with increases in average per person health
insurance premiums. 

 

Home & Community-Based Services 

Health care reform has enacted or enhanced several provisions to expand
home and community based services to help make it easier for people with
disabilities and chronic conditions to live at home and participate in
their communities, rather than having to live in a nursing home or other
institution in order to receive needed services. No one should have to
choose between living at home and receiving the services they need. 

 

Community Living Assistance Services and Supports -CLASS 

The CLASS provisions establish a national voluntary, insurance program
whereby people with functional limitations receive benefits of not less
than an average of $50 per day to pay for services and supports of their
choice that help them with activities of daily living. To qualify,
people will have had to pay premiums, by means of a voluntary payroll
deduction plan, for at least five years. These services can enable them
to remain independent, employed and participate in their communities.
Unlike Medicaid, CLASS does not require people to be impoverished to
qualify for this program. HHS is required to develop an actuarially
sound benefit plan so that the program is self-sustaining. 

 

Community First Choice Option 

Creates the Community First Choice Option. This allows state Medicaid
plans to choose home and community-based services and supports as the
rule, rather than the exception, for Medicaid-eligible individuals with
disabilities with incomes up to 150% of the Federal Poverty Level, who
would otherwise require institutional care. To encourage states to
choose this option, states that opt in will receive an additional six
percent to the federal government's share of Medicaid costs (referred to
as the Federal Matching Assistance Percentage or FMAP) for five years.
Effective October 1, 2011. 

 

Money Follows the Person 

Extends the popular Money Follows the Person demonstration grants until
September 2016. These grants help state Medicaid programs defray the
cost of moving eligible Medicaid recipients who have resided in an
in-patient facility for a minimum number of consecutive days into
community-based settings for eligible Medicaid recipients. 

 

Home and Community Based Services in Medicaid 

Makes it easier for state Medicaid programs to offer home and community
based services by allowing states to do so by amending their state plan,
rather than having to apply for a Medicaid waiver, which can be a
lengthy process. 5 

 

ADDITIONAL IMPORTANT CHANGES

 

Substantial Expansion of People Eligible for Medicaid 

Health care reform substantially increases the number of people who are
eligible for Medicaid. Since many people with disabilities have low or
very modest incomes, this Medicaid expansion will give many more people
with disabilities the right to health care coverage 

As of 2014, health care reform expands Medicaid to cover non-elderly,
childless adults for the first time and adults with incomes up to 133%
of the Federal Poverty Level. It also expands Medicaid to cover children
in families with incomes up to 133% of the Federal Poverty level, and it
extends Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
mandates to all children on Medicaid including those in managed care.
EPSDT services address developmental disabilities and delays. States
will receive an increased Federal matching share for the first few
years. In 2009, 133% of the Federal Poverty Level for individuals was
$14,404 and for families of four was $29,327. 

Between now and 2014, states have the option of extending Medicaid
coverage to these groups. 

In addition, states are required to maintain their current services
under Medicaid and have incentives to cover preventive services and
immunizations without cost-sharing to adults under Medicaid. 

Note regarding Medicare 2-year waiting period. Under existing law,
people found eligible to receive disability benefits under Social
Security's SSDI and other Title II programs must wait two years before
they can receive Medicare benefits. In the meantime, many people with
disabilities go without needed health care, which often causes dire
consequences, including exacerbation of existing conditions and death. 

While health care reform does not directly address this problem, it
mitigates it for some people in the two-year waiting period. They may be
able to obtain health coverage through the temporary high risk pool or
through the health insurance exchanges once they go into effect (which
cannot discriminate on the basis of pre-existing conditions) or they may
qualify for Medicaid under its extended eligibility standards. 

 

Medicare Part D Donut Hole Gap in Prescription Drug Coverage 

Phases out the famous "donut hole" in prescription drug coverage under
Medicare by 2020. Currently, when Medicare enrollees are in the donut
hole (after they reach a certain limit on prescription drug coverage and
before additional coverage kicks in), they must pay for prescription
drugs at full price. 

Provides a one-time $250 rebate for prescription drugs after enrollees
enter the donut hole in 2010. Beginning January 1, 2011, it provides a
50 percent discount on brand name drugs and other discounts for generic
drugs for enrollees in the donut hole. 6 

 

Substantial Increased Funding for Community Health Centers 

Provides an additional $11 billion of funding from the Public Health
Trust fund for Community Health Centers located across all 50 states and
territories (over 1200 facilities). Community Health Centers are major
providers of health care to people who are uninsured or are underinsured


 

Medicare Outpatient Therapy Caps 

Health care reform extends until December 31, 2010 some exceptions to
caps on Medicare Outpatient Part B Therapy Services, thus allowing
Medicare enrollees to get medically necessary therapy services beyond
the $1,860 cap for occupational therapy, and $1,860 cap for physical
therapy and speech-language pathology services. 

 

Accessible Medical Diagnostic Equipment 

Requires the U.S. Access Board, in consultation with the Food and Drug
Administration, to establish regulatory standards setting the minimum
technical criteria for medical diagnostic equipment for people with
disabilities. While existing law requires medical equipment to be
accessible, these standards are intended to clarify how to comply with
this requirement. 

These standards, to be completed in two years, will clarify minimum
technical criteria for medical equipment in doctors' offices and other
medical facilities to be considered accessible for people with
disabilities including people who use wheelchairs. The standards shall
ensure the equipment is accessible to, and usable by, individuals with
accessibility needs, and shall allow independent entry to, use of, and
exit from the equipment by such individuals to the maximum extent
possible. At a minimum medical diagnostic equipment covered by the new
standards will include: examination tables, examination chairs
(including chairs used for eye examinations or procedures, and dental
examinations or procedures), weight scales, mammography equipment, x-ray
machines, and other radiological equipment commonly used for diagnostic
purposes by health professionals. 

 

Elimination of Medicare First-Month Purchase Option for Power
Wheelchairs 

Under existing law, Medicare beneficiaries have the option to purchase
their power wheelchairs, rather than rent them. This enables the person
with long-term need of a wheelchair to have it adjusted to his or her
size and unique needs. Under health care reform, Medicare will only pay
for rental, rather than purchase, of certain power wheelchairs for the
first thirteen months of use (with exceptions for certain classes of
complex rehab power wheelchairs). During the 13-month rental period
Medicare will pay 80 percent and the beneficiary will pay 20 percent of
the rental cost. We are concerned because wheelchairs, like people, are
not fungible. They require many adjustments to meet the individual
user's size and needs. With purchased wheelchairs, suppliers are likely
to bear the cost of individualization, but they are not likely to do so
for a rental that can be so easily returned. Without individualization,
users frequently suffer exacerbated or secondary conditions that require
treatment and often hospitalization, thus offsetting any cost savings to
Medicare. 7 

 

Durable Medical Equipment Excise Tax 

A new excise tax ($20 billion over 10 years) on medical devices will be
imposed on manufacturers of medical equipment. It is intended to help
offset the costs of health reform. Although the tax is imposed on
manufacturers, the consumer will ultimately bear the cost because
manufacturers are likely to pass these costs on to consumers through
increased prices. 

 

Medicare Durable Medical Equipment Competitive Bidding Program 

Existing law requires HHS to implement a competitive bidding program for
suppliers of wheelchairs and other durable medical equipment, under
Medicare, as a cost-savings measure. Wherever competitive bidding goes
into effect, Medicare will only pay suppliers selected by HHS. It is
likely that there will be far fewer suppliers to choose from for both
purchase and repairs of wheelchairs and other durable medical equipment
and that the quality of products and repairs may go down. People who use
wheelchairs may well have to give up their existing suppliers and find
it difficult to get to the new suppliers for repairs. 

Health care reform speeds up the pace of expanding competitive bidding
to additional Standard Metropolitan Statistical Areas and requires
coverage of all areas by 2016. 

 

Medicare Coverage of Annual Wellness Visit Providing a Personalized
Prevention Plan 

Provides Medicare Part B coverage, with no co-payment or deductible, for
personalized prevention plan services. Personalized prevention plan
services means the creation of a plan for an individual that includes a
health risk assessment and may include other elements, such as updating
family history, listing providers that regularly provide medical care to
the individuals, body-mass index measurement, and other screenings and
risk factors. 

 

Comparative Effectiveness Research 

Creates a federal coordinating council for comparative effectiveness
that will be responsible for the annual funding of research to compare
the effectiveness of various treatments on specific conditions.
Comparative effectiveness research compares available treatments to see
which works best based on research findings. 

The law also creates a patient-centered outcomes research institute
responsible for the development of national comparative effectiveness
research priorities and the conduct of clinical outcomes research.
Research must take into account the potential for differences in the
effectiveness of health care treatments, services, and items as used
with various subpopulations, and quality of life preferences. 

 

Training of Future Health Practitioners 

Requires that medical professionals receive disability awareness
training to help reduce the health disparities that exist for people
with disabilities. Grants and other incentives are available to develop
programs and model curricula to train health professionals and 8 

increase the number of health professionals (including dentists) trained
to meet the health care needs of individuals with disabilities. 

 

Nondiscrimination 

Except as provided elsewhere in the law, prohibits discrimination based
on disability under any health program or activity which receives
federal assistance, including credits, subsidies, or contracts of
insurance, or under any program or activity that is administered by an
Executive Agency or any entity established under this title (or
amendments) and provides Section 504 of the Rehabilitation Act as the
enforcement mechanism for violations. The Secretary of HHS may
promulgate regulations to implement this. 

 

Comprehensive Workplace Wellness Programs 

Authorizes an appropriation for grants to eligible small businesses for
the purpose of giving their employees access to comprehensive workplace
wellness programs that meet criteria to be developed by HHS. Employee
wellness programs can be a good way to encourage better health. However,
this provision could inadvertently have a negative impact on people with
disabilities. For example, a person with a disability may be unable to
participate in an exercise program or another benchmark of the wellness
program. If employees who do participate receive a reduced deductible
under the employer-sponsored health plan (or another financial
incentive), the person with a disability who is unable to participate
would end up paying a higher deductible (or would not be eligible for
other financial incentive). To avoid inadvertent negative impacts on
people with disabilities and chronic conditions, it will be important to
work with HHS in designing the programs. 

 

Coverage of Anti-seizure, Anti-spasm, and Smoking Cessation Medications 

Mandates coverage of barbiturates, benzodiazepines, and tobacco
cessation agents under Medicare Part D. Barbiturates include
phenobarbital and other medications that treat seizures. Benzodiazepines
include sedatives, anti-anxiety medications, and anti-spasm medications.
Both of these categories of medications were previously specifically
excluded from coverage under Medicare Part D. 

 

Data Collection and Analysis to Understand and Address Health
Disparities 

Requires the federal government to collect health survey data from
people with disabilities to enable better understanding of the health of
people with disabilities compared to other minority groups. 

Also requires the government to collect survey data from health care
providers in order to learn where people with disabilities receive their
care, the number of providers with accessible facilities and equipment,
and the number of health care professionals trained in meeting the
health care needs of patients with disabilities. 

Requires the development of recommendations for quality measures to
improve the quality of health care for individuals with disabilities.

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