Migraines & Health Reform

Migraines & Health Reform: How will migraine patients be affected?

January 4th, 2011 - Posted by Diana Lee

For people living with migraines one of the most exciting features of the Federal Affordable Care Act, passed earlier this year, relates to pre-existing conditions. Migraine patients currently can be denied insurance coverage based on insurance company policies regarding pre-existing conditions.

A pre-existing condition is a health condition you had before the first day of your coverage
under a new insurance plan. Insurance companies can end up paying a lot of money to treat
your pre-existing condition, migraines included, and will avoid having to do so if at all possible. Unfortunately this leaves many people in our situation completely unable to get insurance coverage.

Here’s how the pre-existing conditions issue affects people with migraines and other similar conditions: If you have a migraine diagnosis, especially if your migraines are not under control, many insurance companies will not cover you (i.e. issue you a policy). Even if you do have what many people would consider good control it can be hard to prove this to the satisfaction of an insurance company. If you will cost the company a lot of money, there is little incentive to give you or your doctor the benefit of the doubt.

Under the new law insurance companies have to cover children up to age 19 who have
pre-exisiting conditions. Right now they can still deny coverage to adults with pre-existing
conditions, but in 2014 this will no longer be legal. In the meantime the Affordable Care Act offers a temporary Pre-Existing Condition Insurance Coverage Program for people with
conditions like migraines who cannot get insurance coverage and don’t have coverage through an employer. Depending on which state you live in you will be covered under a state-run or federal-run program. You can find out how the program is run where you live and about other details here: Pre-Existing Condition Insurance Program.

These are other changes made by the Affordable Care Act that will help people with migraines:

Patients will have the right to appeal insurance plan decisions, including review by someone who does not work for the insurance company.
Insurance companies will be required to offer minimum, basic mental health coverage. This is important for people with migraines because so many of us also live with depression.
You can pick the doctor you want to see from your insurance company’s list of approved providers and see an OB-GYN without a referral.
You cannot be charged more for going to an “out-of-network” emergency room. There will be no requirement that you seek prior approval for the visit.
Insurance companies can’t cancel your policy when you get sick because you made a mistake on your application (applies to policies that start after September 23, 2010).
Insurance companies can no longer impose yearly spending limits or lifetime spending caps on their customers.
For people on Medicare, the Part D “donut hole” will gradually be closed.
When your new plan year begins your insurance provider must cover children up to age 26 and are not allowed to charge more for them than any other child. (But if your child has an offer of insurance from an employer this requirement does not apply.)
A website set up by the federal government will help consumers compare their coverage options. This should help all of us make sense of our very complicated choices.