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The Affordable Care Act: Key Provisions for People With Arthritis

Understand how the law affects your insurance coverage and costs.

The Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010. This law opens offers certain protections to help ensure coverage and access to health insurance for people living with osteoarthritis, rheumatoid arthritis and other types of arthritis. Here is an overview of some of those protections.

You can’t be denied or dropped because of arthritis: Under the ACA, you can’t be refused insurance coverage, be charged higher premiums or get dropped from coverage because of your arthritis.

You can comparison shop for insurance: If you are uninsured or under-insured, you can shop around on the Health Insurance Marketplace at www.healthcare.gov . The plans are broken into four categories:

  • Bronze
  • Silver
  • Gold
  • Platinum

Gold and platinum plans have higher monthly premiums, but you’ll pay lower out-of-pocket costs. That could save you money if you’re paying for several arthritis medicines and rheumatologist visits. You can search and compare details on monthly premiums, annual deductibles and types of services covered. Get the latest updates to key provisions of the ACA visit the U.S. Department of Health & Human Services website . The 2023 open enrollment period runs from November 1, 2022 to January 15, 2023. More information can be found at Healthcare.gov .

You’ll have access to essential health benefits.

Both employer-sponsored health insurance plans and plans offered in the marketplace must cover a list of essential health benefits. These include hospitalization for surgery, prescription drugs, and the management of chronic diseases like arthritis. Co-payments and deductibles for preventive care have been eliminated. To get a full list of the preventive services covered, visit the Healthcare.gov website .

You can’t max out your health coverage.

In the past, some insurance companies limited how much they would pay for coverage over a person’s lifetime. That amount could be up to a $1 million or higher. A million dollars might seem like a lot of money, until you consider that a single hip replacement surgery can cost $100,000 and biologic drugs can exceed $2,500 per month. Currently, insurance companies can’t impose lifetime limits on services that are deemed essential health benefits

You’ll pay lower out-of-pocket costs.

Annual out-of-pocket costs for your medical visits and prescription drugs will be limited, as long as those costs are deemed to be related to essential health benefits. The IRS sets these limits each year. In 2020, the max for an individual is $8,150 and the maximum cost for a family is $16,300.

Your premium payments must largely go to your care.

The government requires insurers spend at least 80% of premium payments on medical care. If they don’t hit 80%, you get a rebate or a reduction in future premium payments.

If you’re on Medicare, your drug costs will be contained.

The "donut hole" is officially closed; however, after you and your Medicare Part D prescription drug plan have spent a certain amount for your medications each year, you still must pay up to 25 percent of the cost of covered drugs. That is called the coverage gap.

You’ll get access to cheaper biologic drugs.

The ACA has paved the way for biosimilar versions of biologics to reach the market more quickly. Biosimilars slow the progression of joint damage similar to biologics, but they’re cheaper. Medicare will reimburse for biological and biosimilars in the same way.

You can appeal rejected claims.

When your health insurer refuses to pay a claim, now you can appeal the decision. If your insurer still says “no,” you can have the decision reviewed by an independent organization. Learn more about appealing claims.

Your child can stay on your plan until age 26.

That’s good news for parents of the nearly 300,000 kids with juvenile arthritis. And even when your young adult needs to find insurance coverage, he or she can’t be denied or discriminated against because of JA.

For more on the ACA visit Healthcare.gov’s quick guide.

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