Living with Diabetes

Health Reform

By improving access to quality health care for all Americans, the Affordable Care Act (the federal health reform law enacted in March 2010) will help reduce health disparities among low income individuals. When fully implemented, the Affordable Care Act will make improvements in preventive and coordinated care, expand Medicaid, end insurance discrimination, and create more affordable health coverage options.

The American Diabetes Association will provide updated information as it pertains to our members on our website as the reforms go into effect. However, for the most up-to-date information, please refer to the new healthcare web portal at www.healthcare.gov. Additionally, for a timeline of what is changing and when, please refer to www.healthcare.gov/law/timeline/index.html.

Medicaid

Medicaid is a program providing medical care for certain individuals and families with low incomes and resources. This program became law in 1965 and is jointly funded by federal and state governments (including the District of Columbia and U.S. Territories). This funding allows states to provide medical care to people who meet certain eligibility criteria.

Currently, there are a number of specific requirements and income eligibility levels vary by state. But, in general, Medicaid covers children, pregnant women, parents of eligible children, people with disabilities that preclude work, and some elderly people. Note: Some people who are elderly or who have a disability qualify for both Medicaid and Medicare. If a person with diabetes is not sure whether he/she qualifies for Medicaid, he/she should apply for Medicaid and have a qualified caseworker in his/her state evaluate the situation.

Medicaid is a state-administered program. Each state sets its own guidelines subject to federal rules. Certain services must be covered by the states in order to receive federal funds, such as in- and outpatient hospital services, doctor visits, and long term care services, such as nursing home care or community-based care. Additional services are optional and are elected by states. For example, coverage of prescription drugs is an optional state benefit, however, every state and the District of Columbia provides prescription drug coverage to Medicaid enrollees. The cost of health care for people in Medicaid varies by state but is extremely limited for most.

Under the health reform law passed in 2010, the Patient Protection and Affordable Care Act (ACA), beginning in 2014, adults and children in families with incomes up to 133 percent of the poverty level (about $15,000 for an individual and $31,000 for a family of four in 2012 in most states) will be eligible for health insurance through the Medicaid program. On June 28, 2012, the U.S. Supreme Court declared the ACA constitutional. As part of that decision, the Supreme Court upheld the Medicaid expansion, however it also ruled that this expansion is optional. This means it is up to each state whether it will expand their Medicaid program eligibility to include nearly all adults and children with incomes up to 133 percent of the poverty level. At this time, it is not clear if every state will expand their Medicaid eligibility as envisioned in the ACA.

How to learn more and apply: The eligibility rules and benefits for Medicaid are different in each state. As a result of the ACA, Medicaid eligibility for some people will be determined in a different way beginning in 2014. Thus, if a person was previously determined ineligible for Medicaid, he/she may want to consider reapplying. To apply for Medicaid in your state, contact your local Medicaid office (look in the blue pages of your phone book for contact information, probably under "Medical Assistance"). Some states let you apply over the Internet, by telephone, or at locations in the community, such as community health centers. A link to your state's Medicaid website can be found at www.medicaiddirectors.org.

More information about Medicaid can also be found on the federal health care website at: http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/index.html.

This website also has information about free or low cost care options:
http://www.healthcare.gov/using-insurance/low-cost-care/index.html.

State Children's Health Insurance Program (S-CHIP)

This program is a low-cost, private health insurance plan that provides health insurance coverage to eligible children until the age of 19. This program serves children in families who earn too much income to qualify for Medicaid but cannot afford health insurance coverage in the private market. Every state's program is unique and individual income eligibility rules and benefits covered vary, but in general, children in families with incomes up to $44,100 per year (for a family of four in 2010) are likely to be eligible for coverage.

S-CHIP generally covers routine doctor visits, dental care, prescription medicines and immunizations, as well as inpatient and outpatient hospital care and other benefits depending on the state. There may be premiums or other cost sharing associated with this coverage but these programs are designed to be affordable. Please go to http://www.insurekidsnow.gov/state/index.html to find specific information about the S-CHIP program in your state or make a free call to 1-877 KIDS NOW (1-877-543-7669).

Health Insurance Exchanges

Starting in 2014, if your employer does not offer insurance or that insurance isn't affordable, you will be able to buy insurance directly through an Exchange in your state. An Exchange will be a new marketplace where individuals and small businesses can buy affordable health insurance that meet certain benefits and cost standards.

Individuals and families earning less than the equivalent of 400% of the poverty level (which was about $43,000 for a single individual or $88,000 for a family of four in 2010) and whose job does not offer affordable coverage will be able to get tax credits to help pay for insurance.

You can search for insurance options available to you at: http://finder.healthcare.gov/.

Some information on this factsheet is from www.healthcare.gov.