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Affordable Care Act

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Now that open enrollment through the exchanges has begun providing newly-eligible people with access to health insurance, patients are getting a firsthand look at what types of insurance will be offered through the Affordable Care Act.

Questions, however, remain about the information available to patients to make an informed decision about their health care and overall understanding of the new law. 

An unsettling poll from the Kaiser Family Foundation earlier this year found a near majority of Americans are unaware that the ACA is law. Combine this with Enroll America’s fall 2012 survey that shows that 78 percent of potentially qualified individuals were unaware of their eligibility, and it is no wonder that some fear the Act will underperform.

Given the lack of awareness in the American populace, and what may seem like a foreign or harrowing new process, these folks who qualify for coverage for the first time need support and good information to help them maneuver through the complicated process of making sure the plan they pick best suits their specific needs – giving them access to doctors and care as well as their required medications and treatments.

To assist this process, the Department of Health and Human Services has created navigators and in-person counselor roles. Local organizations have been tasked with providing fair, impartial and accurate information to assist the newly-eligible with submitting applications, clarifying distinctions between competing plans, and helping individuals make informed decisions based on their unique needs. 

The job of these navigators and in-person counselors cannot be understated; they will help people traverse the sometimes complicated paperwork, industry vernacular and intricacies of the new healthcare system. Having a healthcare plan is only helpful if it gives access to the care and specific treatment and medications that are needed. Patients coping with pain have likely endured a long process – in consultation with their physician – around what medication and regime works best for them. If they are forced to switch their medication because their current drug is unaffordable, their situation becomes unbearable. 

Moreover, what good is insurance coverage for a person with cancer if it doesn’t cover the cost of their treatments? What patient with high blood pressure is better off if their meds are not covered or discounted through their health plan? These are the kinds of issues that will make these supporting roles critical in linking people to the right plan.

The whole process can be intimidating, especially on one’s maiden voyage into the sea of differing health insurance options. Therefore, it is helpful to keep in mind some basic questions that will guide the way through the new health insurance marketplace.

Questions about what medications are covered by which plans, and how much will you be responsible for paying? These are questions that it is not too early to start thinking and asking about.  Here are some additional questions to consider and ask as this process unfolds:

·      Does the health plan cover any medications I am currently taking? 

·      What is the co-pay or co-insurance required for medications and treatments? What must I pay out of pocket?

·      Are there any additional costs to me? Can you explain these costs? 

·      Does the health plan require prior authorization from the plan before I get the medicine or treatment prescribed by my doctor? 

·      Does the health plan require me to fail on another medication before covering the medicine prescribed by my doctor? 

·      Where do I go to file a complaint if I can’t find the coverage I need?

Ready or not, these changes are coming. While we would hope for a smooth transition, chances are there will be some challenges along the way. What cannot get lost in the shuffle is access to the medicine some of these patients rely on daily. Armed with these questions, and access to navigators and counselors, patients can feel more empowered as they make important decisions for their health. Isn’t that what the Affordable Care Act is really all about?  

Paul Gileno, who suffers from chronic pain, is the president and founder of the US Pain Foundation, which is based in Connecticut. 

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