Before the Affordable Care Act went into effect in 2014, health insurance companies were legally allowed to exclude and/or refuse to cover whatever they wanted in their plans. It didn’t matter if it was a flu shot or in-patient hospital care after a car accident, whatever was in the contract was what both parties agreed to, and it didn’t matter whether any medication or treatment was required to stay alive. Companies would refuse to pay for anything from diabetes testing strips to chemotherapy, because it was allowed. Since the Affordable Care Act, plans are now required to cover one drug in each category of the U.S. Pharmacopeia, or compendium of drug information.
How the Affordable Care Act Changed the Rules on Medication
The year 2014 was an interesting one for health insurance in many ways, with the rollout of the ACA, or Obamacare, greatly evolving the industry. Some health insurance providers kept their old plans for the rest of the year after Obamacare went into effect, so that people’s plans wouldn’t just be changed out from underneath their noses. This continued many exclusions even after the ACA went into effect. Before the ACA, insurance companies could charge you more, deny you coverage, or exclude benefits if you had a life-threatening or chronic health condition. Now, they cannot charge you more or deny coverage to you based on pre-existing conditions or your current health.
Similarly, if the medical treatment for a patient’s serious illness made its way into a gray area with experimental treatments, health insurance companies could refuse to pay for it. Now that healthcare reform has happened, insurers have to give explanations for why a claim was denied and simultaneously inform you of what steps can be taken to challenge that decision. Even if your insurer’s own internal review examines and then re-denies your claim, you can now request an external review by an independent organization which has the power to overturn their denial of coverage.
Obamacare Mandates Prescription Drug Coverage
Luckily, prescription drug coverage is one of 10 essential health benefits that are required by the ACA. What this means is that insurers are no longer legally allowed to add on a prescription drug benefit plan to a healthcare plan at an additional price. And because the ACA requires that one drug in each category of the U.S. Pharmacopeia be covered, there should now always be a covered drug available for a condition. While brand names are not required to be covered, the cost of a generic or alternate brand must be provided for. In addition to this, patients and doctors can now also request and be granted access to clinically appropriate drugs that are not covered by individual health plans.
In conclusion, since the Affordable Care Act, health insurance companies can no longer refuse to pay for necessary medication when there is no alternative. If there is only one drug in a category, it’s covered, and if there are several, at least one is required to be covered. It’s also important to note that the ACA also now counts prescription drug costs toward out-of-pocket caps on medical expenses. So, required medications are now covered and also count toward your individual plan’s cap on medical expenses.