Download Tip Sheet: What Parents of Children with Disabilities Need to Know about Changes in the ACA





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What Parents of Children with Disabilities Need to Know about Changes in the ACA

May 25, 2016

The Department of Health and Human Services issued some new rules for health plans sold in the federal exchange next year.  This is good news, as these changes will give consumers more information about health plans and make it easier to compare plans.  Kaiser Health News  recently reported on three major changes that consumers will see.   Please note that these changes apply only to the 38 states using the federal exchange.


Additional information on the networks of plans

Medical PencilFamilies will now have more information on which providers and hospitals are in their plan’s network.  Besides the cost of the plan, most parents are concerned if their child’s doctor or hospital is participating in the plan.  The new change would require 30 days’ notice if a provider is leaving the plan.  In addition, if a child is undergoing treatment, coverage of the provider must continue for 90 days to avoid interruption of service.  The only exception is if the provider is being “dropped for cause.”  Consumers will also be able to assess the general scope of a plan’s network more easily because the federal government will label each plan by network size (such as basic, standard or broad).


Reducing out-of-network surprise bills

Medical BillsSome consumers are finding that, even if a hospital or provider is in their plan, they are still getting hit with a bill from another provider in the facility who is out-of-network, such as an anesthesiologist for surgery.  This new change gives insurers an incentive to inform consumers if they may be treated by out-of-network providers in an in-network facility.  Unless the consumer gets notice 48 hours ahead of treatment, the out-of-network costs paid by the consumer will count towards the out-of-pocket maximum.  This is the amount that families must pay each year before insurance will cover all of the essential health benefits for the rest of the year.  For more information on avoiding surprise medical bills, see our previous blog.


Consistent information on out-of-pocket costs

Binders of policies, procedures, provider networksAnother change should make it easier for consumers in some markets to compare the cost of plans.  The federal government is establishing six of standardized plans that insurers can choose (but are not required) to offer.  All plans in each standardized category would have the same deductible, a four-tier drug formulary, and a single in-network provider tier.  Each standardized plan would also cover the same specific services (e.g., certain drugs and doctor’s visits) at specified co-payment levels without the need to meet the plan’s deductible.  The copays (payments made for each visit or medication) are highest for bronze plans, which are the lowest- cost plans, and less for silver and gold plans.  

These changes in network information, out-of-network bills, and out-of-pocket costs will make the Marketplace more “user friendly.”  Families of children with special health care needs will be able to better compare plans to get the best care for their child.



Reducing Costs:

Three Changes Consumers Can Expect in Next Year’s Obamacare Coverage:   


Lauren Agoratus


Lauren Agoratus is the parent of a child with multiple disabilities who serves as the NJ Coordinator for Family Voices. She also serves as the southern coordinator in her state’s Family-to-Family Health Information Center.

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