SOURCE: Allsup


March 07, 2012 11:14 ET

Affordable Care Act Turns Two: Passing But Incomplete Grade for People With Disabilities and Seniors

Allsup Offers Progress Report on Key Provisions for People Awaiting SSDI Benefits and Those Relying on Medicare; Supreme Court Ruling Could Impact Final Outcome

BELLEVILLE, IL--(Marketwire - Mar 7, 2012) - The Patient Protection and Affordable Care Act of 2010 (ACA) marks its two-year anniversary March 23, 2012, with mixed results for people with disabilities and those relying on Medicare, according to Allsup, a nationwide provider of Social Security disability representation and Medicare plan selection services.

"Seniors and people with disabilities are among the most vulnerable groups needing continuous access to affordable care," said Paul Gada, personal finance director for Allsup. Gada directs Allsup Medicare Advisor®, a Medicare plan selection service for people with disabilities and individuals over 65.

"For Medicare recipients, the results of healthcare reform have generally been positive. But for people with disabilities, still awaiting Medicare eligibility, the results have not been as strong," Gada said.

He added the major question looming is what impact the U.S. Supreme Court will have on the ACA's future. The Supreme Court will hear oral arguments the week of March 26 related to two major provisions of the ACA: the individual mandate requiring most people to maintain a minimum level of health insurance coverage beginning in 2014 and the Medicaid expansion provision.

Below, Allsup offers a progress report on key aspects of the ACA provisions implemented so far based on its experience working with seniors and people with disabilities. People applying for Social Security Disability Insurance (SSDI) may have to wait months, even years, to be awarded benefits. These individuals often have limited or no source of income and few healthcare coverage options. In addition, people who rely on SSDI benefits are eligible for Medicare following a 24-month waiting period.

  • Pre-Existing Condition Insurance Plans (PCIPs) -- Progress report: Coverage, but at a cost, and with hurdles.

    Starting in 2014, insurers can no longer deny coverage to people with pre-existing health conditions. In the interim, the law created PCIPs that offer people with pre-existing conditions who can't get coverage elsewhere insurance at the same market rates as healthy consumers. In some cases, the plans offer discounts up to 40 percent. The plans are state-run in 27 states. The U.S. Department of Health & Human Services (HHS) runs plans in the remaining 23 states and the District of Columbia. While costs vary widely by state, each participant is expected to pay $28,944 in medical costs in 2012 -- more than double what had been predicted in November 2010, according to a February report by HHS' Center for Consumer Information & Insurance Oversight.

    "Allsup has found that about one-third of individuals with serious disabilities will lose their health insurance while going through the SSDI process," Gada said. "The PCIPs offer some of these individuals an option. However, the coverage is still too costly for many people who can no longer work due to a disability."

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  • Elimination of Lifetime Limits, Regulated Annual Limits and Coverage for Young Adults -- Progress report: Helping some people with disabilities that would otherwise lose coverage.

    As of September 2010, insurance plans were barred from imposing lifetime dollar amounts on critical benefits, such as hospital stays. Restrictions were added on annual limits on the dollar value of coverage. In addition, parents were allowed to keep their adult children up to age 26 on their health plans, giving younger people who suffer a disability an added safety net.

    "Many people with disabilities have costly, chronic medical conditions. Even before they applied for SSDI, they could have spent several years paying for treatments and exhausted their insurance lifetime limit," Gada said. "It's reassuring for them to know they can no longer be turned away when they most need coverage. At the same time, annual limits also need to be eliminated entirely, which won't happen until 2014."

  • Preventive Services for Seniors -- Progress report: Unfortunately, still one of the best-kept secrets of healthcare reform.

    Starting in September 2010, the ACA required all new health plans to cover certain preventive services, such as mammograms and routine vaccinations without charging a deductible, co-pay or coinsurance. This was extended to Medicare plans in 2011. While the government estimates that about 25 million individuals with traditional Medicare used one or more preventive services last year, awareness is still low.

    "We know from our research that many seniors likely don't know what preventive services are covered and, therefore, don't intend to take advantage of them," Gada said. "This is particularly true among older Medicare beneficiaries. So it's important that caregivers and healthcare providers continue to try to get the word out."

  • Reductions of the Medicare Prescription Drug Donut Hole -- Progress report: The coverage gap is shrinking, but still costly.

    Starting in 2011, Medicare beneficiaries reaching the donut hole received a discount when buying Medicare Part D plans. Currently, this discount is 50 percent on brand-name and 14 percent on generic drugs. The gap, which is $4,700 in out-of-pocket costs, will continue to shrink until it is fully eliminated in 2020. This provision clearly provides relief to individuals in the gap who are taking brand-name drugs; however, due to the cost of some drugs, such as biologicals, expenses can still be quite high until catastrophic coverage is reached.

The Future: ACA's Advancement or Retreat May Rely on Supreme Court

Two ACA provisions -- state health insurance exchanges and expanded Medicaid coverage -- are set to take effect in 2014. For people who cannot afford coverage in the private market, even under PCIPs, these two provisions should offer needed support. The state exchanges will allow individuals to compare qualified plans and provide them with information on whether they are eligible for Medicaid, the Children's Health Insurance Program (CHIP) or other programs to reduce the costs of insurance. At that time, Medicaid in every state will cover people under age 65 who have income of 133 percent of the federal poverty line (the poverty line is $23,050 for a family of four in 2012).

"It's not uncommon for someone with a disability to initially have too many assets to qualify for Medicaid, but then to spend down those assets while awaiting SSDI," Gada said. "The state exchanges could be important in providing a bridge as people transition to different plans, but it's essential they truly do provide affordable coverage."

Gada added that these future provisions and changes already enacted under the law are likely to come under intense scrutiny with the U.S. Supreme Court's review. "The Supreme Court ruling will look at both the individual mandate to have insurance and the expansion of Medicaid. Aspects of the law, such as healthcare exchanges, may be affected significantly. It remains to be seen how the ACA ultimately affects healthcare for people with disabilities and seniors going forward."

Social Security Disability & Medicare Help

Find more resources for people with disabilities, and answers to questions about Social Security disability benefits at or contact Allsup's Disability Evaluation Center at (800) 678-3276.

Find answers to Medicare questions by contacting the Allsup Medicare Advisor®, which works one-on-one with individuals to help them choose the Medicare plan that best meets their needs, at or call (866) 521-7655.

Allsup is a nationwide provider of Social Security disability, Medicare and Medicare Secondary Payer compliance services for individuals, employers and insurance carriers. Founded in 1984, Allsup employs more than 800 professionals who deliver specialized services supporting people with disabilities and seniors so they may lead lives that are as financially secure and as healthy as possible. The company is based in Belleville, Ill., near St. Louis. For more information, go to or visit Allsup on Facebook at

The information provided is not intended as a substitute for legal or other professional services. Legal or other expert assistance should be sought before making any decision that may affect your situation.

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