People with disabilities historically have experienced difficulty purchasing healthcare insurance in the individual commercial market because some insurers would not provide coverage for people with pre-existing conditions and also because policies could be prohibitively expensive. (An estimated 3.5 million people with disabilities did not have health insurance when the Affordable Care Act was enacted in 2010.) Even when people with disabilities could obtain group healthcare coverage through their employer or they were covered by a family member’s policy, the health care benefits they needed might have been limited or not available at all, co-pays also might have been prohibitively expensive, and annual or lifetime benefit limits on certain types of services, care, and equipment could have prevented them from obtaining the care they required. Moreover, most people who become disabled before the age of sixty-five and are eligible for Medicare still face a two-year waiting period for coverage, frequently leaving them with no healthcare insurance at a time when they need it most. (see the National Council on Disability, The Current State of Health Care for People with Disabilities)
The specific problem of historic discrimination in health insurance coverage for mental illness and substance abuse treatment led to the enactment of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA), a federal law that required group health plans and group health insurance coverage (both public and private) that offered mental health and substance use disorder treatments to offer coverage that is “generally comparable” to the medical and surgical care offered in the plan. MHPAEA did not require plans to offer those treatments in the first place, however, and the act also did not apply to the small group or individual insurance market. (However, numerous state mental health parity laws applied to small group insurance plans, typically defined as a plan that covers 50 or fewer employees. The ACA amended this definition to 100 or fewer employees, but states can choose to maintain a definition of 50 or fewer until 2016.) In 2010 the Affordable Care Act (ACA) extended the reach of the MHPAEA in two critical ways. First, “mental health and substance use disorder services, including behavioral health treatment” is one of the ten categories of Essential Health Benefits (EHB) that must be covered as of January 1, 2014 by non-grandfathered plans* in individual and small group markets, both inside and outside of the Marketplace. Second, HHS enacted regulations under the ACA that extend MHPAEA’s parity requirements to the EHB mental health and substance use disorder category. (HHS estimates that as a result, approximately 11 million people with current individual market coverage and 24.5 million people with current small group coverage should be able to get access to mental health and substance disorder that is comparable to their general medical and surgical coverage. In additional, an anticipated 27 million currently uninsured individuals will gain access to health coverage through private health insurance, the Marketplaces, and Medicaid that will include mental health and substance use disorder services that must be generally comparable to their medical and surgical plan coverage.)
The Health Insurance Marketplace therefore offers an excellent opportunity for people with all disabilities who either have gone without coverage or have had limited access to needed health care benefits to obtain health insurance in the individual market. It also affords an opportunity for some people who have costly individual coverage to lower the cost of their health insurance and/or obtain adequate coverage for the services, medications, or equipment they require by switching policies. In addition, the Marketplace offers some people with disabilities the opportunity to determine their eligibility for Medicaid under both existing and new expansion rules and for other federal or state health care benefits such as the Children’s Health Insurance Program (CHIP).
* “Grandfathered” plans are plans that existed when the Affordable Care Act was enacted (i.e., March 23, 2010) that have not been changed in certain specified ways