Affordable Care Act: FAQs

The Affordable Care Act (ACA), also known as health care reform, is comprehensive and complex. Here are a few frequently asked questions (FAQs) to help guide you through the changes and what they mean for you. Get more on ACA basics here. PAN will continue to update this FAQ resource as new information becomes available.

Do you have questions? Please send them to Jamie Tucker at [email protected].

ACA Question of the Week

I am now on permanent disability and will soon start receiving Social Security Disability Insurance (SSDI) payments. I don’t have health insurance and won’t be eligible for Medicare for two years because of the waiting period for SSDI payment recipients. What are my options to obtain coverage?

Click here for the answer.


Table of Contents

Additional FAQ Resources

The Kaiser Family Foundation has developed quick-reference FAQs on the following Affordable Care Act topics:

Health Exchanges/Marketplaces
Employer-sponsored Health Insurance

The Affordable Care Act: What is it?

1.    What is the Affordable Care Act?

The ACA is the most sweeping, comprehensive expansion and regulatory overhaul of the United States health care system since Medicare and Medicaid were created in 1965.
Signed into law by President Obama on March 23, 2010, the ACA is designed to increase the affordability and rate of health insurance coverage for Americans, and reduce the overall costs of health care for individuals and the government.

2.    What has already happened?

Since ACA became law in 2010, a number of key changes to our nation’s health care system have been implemented:


  • Eliminated lifetime limits on insurance coverage
  • Prohibited denying insurance coverage to children based on pre-existing conditions
  • Extended coverage for young adults by allowing them to remain on their parent’s plan until age 26
  • Prohibited insurance companies from rescinding coverage based on technical errors on consumer applications

Learn more about key 2010 reforms


  • Free preventive care is provided for seniors
  • Seniors who reach the coverage gap (“donut hole”) receive a 50% discount when buying Medicare Part D covered brand-name prescription drugs
  • Established the Center for Medicare and Medicaid Innovation (CMMI)
  • Established the Community Care Transitions Program to help high risk Medicare beneficiaries who are hospitalized avoid unnecessary readmissions by coordinating care and services

Learn more about key 2011 reforms


  • Established a hospital Value-Based Purchasing Program (VBP) in traditional Medicare that offers financial incentives to hospitals to improve the quality of care
  • Established “Accountable Care Organizations” (ACOs) that provide incentives for physicians to join together coordinate patient care and improve outcomes

Learn more about key 2012 reforms

3.    What’s happening now and what’s coming next year?

The next year and beyond will bring a number of broad, structural changes to our nation’s health care system.

The biggest development in 2013 is that states and the federal government are formally developing and implementing Health Insurance Exchanges.

Learn more about key 2013 reforms


  • Health Insurance Exchanges will be active in every state nationwide
  • With some exceptions, all Americans will be required to have health insurance
  • Annual limits on insurance coverage will be eliminated
  • Insurance coverage discrimination based on pre-existing conditions or gender will be prohibited
  • Insurance coverage will be ensured and protected for individuals participating in clinical trials

Learn more about key 2014 reforms


The ACA and You

1.    What do the ACA changes mean for me?

The Affordable Care Act impacts everyone, from infants and young adults to seniors. Whether or not you have existing health care coverage, the types of health care services available to you will expand. For people with chronic conditions like Parkinson’s, there are a number of changes designed to make receiving care much easier. As highlighted above:

  • Insurance companies can no longer deny coverage based on pre-existing conditions (effective in 2014)
  • Annual coverage limits are eliminated (effective in 2014)
  • Lifetime coverage limits are eliminated (effective in 2010)
  • Preventive conditions for your overall health are now provided at no direct cost (effective in 2011)
  • You are protected if you choose to participate in clinical trials (effective in 2014)

2.   What is the individual mandate? Who is required to have health insurance?

Beginning in 2014, all Americans – with some exceptions – are required to have health insurance coverage or face a penalty. The good news is that if you already have existing qualified health insurance, you meet this requirement. Qualified health insurance plans (QHP) may include:

  • Government-sponsored plans, such as:
    •    Medicare or Medicaid
    •    Children’s Health Insurance Program (CHIP)
    •    TRICARE
    •    Veterans health care programs
  • Employer-based or sponsored health care plans
  • Individual private coverage

If you don’t have insurance and don’t meet one of the exceptions described below, then you will be eligible to purchase coverage through your state-based exchange or marketplace beginning October 1.

If you are required to have health insurance, but do not obtain coverage in 2014, you will be assessed a penalty or fee that equals 1% of your yearly income or $95, whichever is higher. The fee for uninsured children is $47.50 per child. The fee increases to $325 or 2% of yearly income in 2015. The fee is assessed when you file your federal income tax return.

Uninsured individuals will not be required to buy insurance or pay a penalty if:

  • They are low income and premiums are considered to be unaffordable (defined as premium cost that exceeds 8 percent of household income)
  • They are not required to file a federal tax return because their income is too low
  • They would qualify under new income limits for Medicaid, but their state has chosen not to expand Medicaid eligibility
  • They are uninsured for less than 3 months of the year
  • They are a member of a federally recognized Native American tribe
  • They participate in a health care sharing ministry or belong to a recognized religious sect that has religious objections to health care
  • They are granted a hardship exemption (applications for hardship exemptions will be available through the exchanges)

To learn more, view this helpful infographic from the Kaiser Family Foundation and visit

3.   I am required to purchase coverage on my own but worried I won’t be able to afford it.

Beginning in the 2014, the ACA authorizes premium assistance tax credits to help low and modest income individuals and families purchase health insurance coverage through the insurance exchanges or marketplaces.

Who is eligible for these premium credits?

  • Citizens and legal residents (including families) with incomes between 100% and 400% of the federal poverty level (FPL) who purchase coverage through their state’s exchange.

People eligible for public coverage (including Medicare and Medicaid) are not eligible for premium assistance in the exchanges. People offered coverage through their employer are also not eligible unless the employer plan is considered to be insufficient or unaffordable.

How are the credits calculated?

The amount of the tax credit that a person can receive is based on the premium cost of the mid-tier (silver) plan in the exchange and state where the person is eligible to purchase coverage. This means that the value of the premium credits will vary by state.

For people with incomes between 100% and 400% of the FPL, the maximum cost of their health insurance premiums is capped on a sliding scale as a percentage of their income.

Income Level   
Up to 133% of FPL
133-150% of FPL
150-200% of FPL
200-250% of FPL
250-300 of FPL
300-400% of FPL
Premium Limit as Percentage of Income
2% of income
3-4% of income
4-6.3% of income
6.3-8.05% of income
8.05-9.5% of income
9.5% of income

Here’s an example of how the process might work:

  • John is single and has an income in 2014 that is 250% of poverty (about $28,735).
  • The cost of the second lowest cost mid-tier plan in the exchange in John’s area is projected to be about $5,733 for the year.
  • Under the premium limits, John would not be required to pay more than 8.05% of income, or $2,313, to enroll in the mid-tier plan.
  • The tax credit available to John would then be $3,420 ($5,733 premium minus the $2,313 limit on what John must pay).

Although information on premium costs is not available in many states, the Kaiser Family Foundation has created a premium credit calculator to help you determine if you qualify for assistance and estimate the amount of your credit.

4.   What happens with my health insurance coverage if I want to participate in a clinical trial? 

Right now, insurance coverage during a clinical trial varies state by state in accordance with state law (this guide from the American Cancer Society will show you what is covered in your state in 2013), but that all changes beginning in 2014.

Under the ACA, starting on January 1, 2014, health insurance carriers will be required to cover the “routine patient clinical trial-related costs” of people taking part in clinical trials. Insurers will no longer be allowed to drop or limit coverage because a person chooses to take part in a clinical trial, and this rule will apply to all clinical trials that treat cancer or other life-threatening diseases like Parkinson’s.
The ACA defines these “routine” patient costs that insurers must cover in terms of the items and services that a health plan would normally cover if the patient wasn’t involved in a clinical trial. This includes such things as hospital visits, imaging or laboratory tests, and medicines.

However, there are still a few things that insurers will not be required to pay for:

  • The treatment, device, or service that is being studied and is usually covered by the trial’s sponsor
  •  Items and services only needed for data collection and analysis and are not used in direct patient care
  • Any service that is clearly not in line with widely accepted and established standards of care for a certain diagnosis

For more information, please consult this helpful clinical trial Q&A document put together by the American Society of Oncology.

5.   What does the employer-based insurance mandate delay mean for me? 

The ACA and its requirements are extremely complex, and it’s important to first clarify exactly what the “employer mandate” is supposed to accomplish.

Employer mandate
At its core, the employer mandate requires large, private employers – those defined as having 50 or more full time equivalent employees – to offer affordable, qualified coverage to employees or face a penalty.

  • Affordable coverage means that the employee share of the insurance premium cannot be more than 9.5% of the employee’s household income.
  • Qualified coverage means that the plans offer essential health benefits and cover at least 60% of health-related costs.

If coverage exceeds that amount or doesn’t meet the qualified standard, the employee can then apply for premium assistance to buy insurance through the Exchange – and the employer would face a penalty for the coverage being too expensive.
In order to ensure that the large employers are offering affordable coverage, they will be required to report this information to the IRS.

Employers with fewer than 50 employees have always been exempt from these requirements under the ACA.
What the Delay Means
In early July, the Administration announced that it would give employers covered by the mandate, one year of transitional relief to help them better prepare their systems to report the necessary information to the IRS. As part of this relief, the Administration also said that large employers would not be subject to penalties for not offering coverage until 2015.
Technically speaking, the delay is only related to the reporting of information – meaning that the protections in place for employees still remain.  Here are a couple of examples:

  • If an employer decides to raise premiums dramatically in the one-year period before reporting is mandatory and the cost of the premium is more than 9.5% of the employee’s household income or doesn’t offer qualified coverage, the employee is entitled to apply for premium assistance to buy coverage through the Exchange.
  •  If an employer decides to drop employee coverage in the one-year period before mandatory reporting, the employee is entitled to apply for premium assistance to buy coverage through the Exchange.

Either way, the employee has options for more affordable coverage in 2014 if the employer makes drastic changes.

The Kaiser Family Foundation has provided this helpful infographic to show how the employer mandate will work.

6.   What happens if I’m denied coverage for a particular drug or therapy?

Under the ACA, starting in 2014, there are new rules to help you if you are denied coverage of a particular drug or therapy and all new insurance plans must have procedures in place to ensure that enrollees have access to medically necessary drugs that may not be included in the plan’s list of approved drugs, also known as the “formulary.”

A treatment is considered medically necessary if it meets any of the following criteria:

  • The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
  • The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition or disability.
  • The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

There are now two levels of appeal, an “internal” review process and an “external” review if your internal appeal is denied.

Steps in the Internal Appeal Process:

  • Contact your prescribing/treating physician and ask him/her to contact your insurer’s medical management area or medical director to request a peer-to-peer review to discuss the specific reason why you need this type of medication.
  • If your physician has already had the peer-to-peer review with the medical management staff, and the request for medication continues to be denied, you have the right to appeal this decision in writing to the appropriate department. You can find the address to submit appeals in the denial letter, your coverage documents, or by contacting your insurer.
  • In the letter, be sure to include:
    • Pertinent clinical information regarding your health and medication history.
    • History of any adverse reactions or side effects you have had to similar medications (over the counter or prescribed), or generic equivalents that were not effective.
    • A drug authorization form, if required by your insurer.
    • Information that directly addresses any reason given for the denial.
    • A letter of medical necessity from your physician if applicable that asserts:
      • Any drug on the formulary would not be as effective and/or would be harmful to you.
      • All other drug or dosage alternatives on the plan’s formulary have been ineffective or caused harm – or, based on sound clinical evidence and knowledge of the patient, are likely to be ineffective or cause harm.
  • After submitting your request, contact your insurer to make sure it was received.
  • Follow-up.

External Appeal
If your internal appeal is denied, you have the right to request a second-level or independent external review. This will be a reconsideration of your original claim by professionals with no connection to your insurance plan. Your plan must include information on your denial notice about how to request this review. A request should include the letter with the information listed above unless the denial letter requires different or additional information. The external review process may vary slightly by insurer.

Appeal Timeframe
Some group plans may require more than one level of internal appeal before you’re allowed to submit a request for an external review. However, all levels of the internal appeals process must be completed within the following timeframes:

  • 72 hours after receiving your request when you’re appealing the denial of a claim for urgent care.
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of services you have already received.

For more information on your insurance plan’s exceptions and appeals process, please contact your provider.


Health Care Exchanges/Marketplaces

1.    What are the Health Insurance Exchanges/Marketplaces?


The Health Insurance Exchanges (or Health Insurance Marketplaces) are state-based marketplaces through which individuals and small employers can purchase health insurance. Each state will have its own Health Insurance Exchange. While the plans offered in the Exchanges will have to meet certain standards, the Exchanges themselves will look and operate differently state by state. 

The Exchanges are designed for those who currently purchase insurance in the individual market. This group will include, for example, early retirees (pre-Medicare eligible retirees), the self-employed, individuals whose employers do not provide insurance, or those who cannot afford their employer’s insurance. Employers with fewer than 100 full time employees will also be able to purchase insurance through the Small Business Health Options Program (SHOP) Exchanges in 2014. 

All Exchanges must be set up by January 1, 2014 and the open enrollment period to purchase insurance through the Exchanges begins October 1, 2013.

View this interactive map to see how your state exchange will be structured.

2.    Do I have to purchase insurance through my state’s Exchange?

Not everyone is required to purchase insurance through their state Exchange. Here are few questions to help you determine if you’re eligible.

Health Care Exchange Checklist

Do you already have existing private health care insurance?
Yes. If you already have health insurance coverage individually or through an employer in 2014 - you do not have to worry about purchasing insurance through your state Exchange. If this changes and you lose your insurance, you will need to either replace that coverage through the private market or through the Exchange in your state.

Do you have Medicare?
Yes. You also do not have have to worry about enrolling in coverage through your state’s Health Care Exchange. Medicare qualifies as health care coverage under the ACA and isn’t part of the Health Insurance Marketplace. If you have health care coverage through Medicare, you don’t need to do anything.

The Marketplace won’t affect your Medicare choices, and your benefits won’t be changing. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have the same benefits that you have now. The Medicare open enrollment period (October 15 – December 7) will also remain the same.

If you currently qualify for Medicaid, you also don’t have to worry about purchasing insurance through your state’s Exchange

Do you have insurance coverage through a veterans health care program offered by the VA?
Yes. The VA Health Care plans meet the qualified health plan requirement of the ACA. You do not have to purchase insurance through your state’s Exchange.

Learn more about VA Health Care.

Are you uninsured?
Yes. If you are currently uninsured or you current coverage will lapse by the end of the year and you do not plan to renew, then you will be eligible to purchase insurance through your state Health Insurance Exchange. Under the new mandate you must have qualifying health insurance or your will be subject to a penalty through your income taxes. provides a number of resources to help you learn more about how your state will provide care through their Exchange. Within the next few months and by October 1, each state should also have a unique Exchange website and processes for helping you find the information you need to buy coverage. There will also be subsidies available for individuals who need assistance in paying premiums.

Keep checking and your state government’s website for more information on your state’s Exchange.

3.    What can I expect from insurance plans offered through the exchanges or marketplaces?

Beginning in 2014, all new or renewed private insurance plans, including those offered in your state-based exchange or insurance marketplace, will have to meet new, standardized requirements. Under the ACA, insurers will be required to offer plans that fit within four levels of coverage:

  • Bronze
  • Silver
  • Gold
  • Platinum

Insurers don't have to offer plans in all four levels, but within the health insurance Exchanges, all insurers must offer at least one bronze, one silver, and one gold plan.

Each plan level must cover the same set of minimum essential health benefits (EHB), and no health plan will be allowed to charge cost-sharing - including deductibles, co-payments, or co-insurance - greater than the limits set for high-deductible plans ($6,350 for individuals; $12,700 for families in 2014).

The minimum EHBs include:

Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse services
Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive, wellness, and chronic disease management Pediatric services

Plan Value

While the scope of benefits will be the same among the plans, the value of those benefits will vary across the bronze, silver, gold, and platinum levels. This means the amount of cost-sharing required will differ in those tiers.

The four levels of coverage are based on actuarial value, which is essentially the percentage of health costs that an insurance plan will pay for a covered individual. If the actuarial value of a plan is 70%, for example, then the plan will cover 70% of an individual’s health costs, with individual responsible for the remaining 30%. Your state Exchange will provide you with information to help you compare the plans as you prepare to purchase.

Bronze 60% of costs covered by plan
Silver 70% of costs covered by plan
Gold 80% of costs covered by plan
Platinum 90% of costs covered by plan

If you are planning to purchase individual coverage through your state Exchange, visit for more information, including a link to your state-specific Exchange website if it is available (all states will have an Exchange web portal by October 1).

Remember, if you already have coverage, such as Medicare, you are not required to purchase insurance through your state Exchange.

4.    How are prescription drug benefits treated by private health insurance plans in the Exchanges?

Prescription drug coverage is one of the ten benefits included in the Essential Health Benefits (EHB) package that must be offered as part of all new private individual or small group market plans, both inside and outside of the Exchanges, beginning in 2014.

For prescription drug coverage, plans must cover the greater of:

At least one drug per category
and class
OR The same number of prescription drugs
in each category and class as your state’s
benchmark plan

This means that if your state’s benchmark plan covers four drugs in a particular category and class (the drug category is the broader drug type classification, like Anti-Parkinson Agents, while the class is a smaller drug subtype, like dopamine agonists), then these four drugs must be available as part of prescription drug coverage for new individual and small group market plans.

Aleast one drug will be available for each category and class, but in most cases it will likely be more. For example, the South Carolina benchmark covers 13 total Anti-Parkinson medications, while the Oregon benchmark covers 14.

Originally, the EHB proposal for prescription drugs only required covering one drug per category and class. Recognizing the potential burden for people with chronic diseases like Parkinson’s, who often rely on multiple therapies to manage their condition, PAN advocated successfully to modify the rule to allow for more expansive drug coverage (Learn more about PAN’s efforts on EHBs).

Medical Necessity
Plans must also have procedures in place to ensure enrollees have access to medically necessary drugs that are not included on the plan’s list of approved drugs, also known as the “formulary.” (We’ll cover what these procedures will look like in our next FAQ.)

How do I find my state’s benchmark for prescription drug coverage?
The Center for Medicare and Medicaid Services Center for Consumer Information and Insurance Oversight (CCIIO) has comprehensive information for each state’s EHB benchmark insurance plans, including the category and class of prescription drugs that must be covered.

This is information will also likely be available when the plan enrollment for your state Exchange goes live on October 1.

Remember, if you already have coverage, such as Medicare, you are not required to purchase insurance through your state Exchange.

5.    I’m having trouble finding the information I need on What should I do?

Since the launch of the Health Care Exchanges (or Marketplaces) on October 1, has had a series of technical glitches and other issues, some of which may come up again periodically throughout the open enrollment period.

For those purchasing insurance on the individual market (except people with Medicare, Medicaid, other government-sponsored health insurance, or employer-based insurance), it’s important to remember that the system is designed for you to take your time, compare plans, and make the best choice for you and your family.

While you must have a plan set by December 15 in order for your coverage to begin on January 1, you will still have until March 31, 2014 to select a plan to avoid any non-coverage penalty.

If you’re having trouble navigating to find the information you need, here are a few resources that should be helpful.

Finding Your Exchange
If you are unsure of how your Exchange is operated, visit and use the “Find My State” feature. Once you enter your state, information will be provided on how to access your state’s Exchange web portal.

If your Exchange is state-run, you will be redirected to your state’s Exchange website, where you will be able to compare plans and fill out an application. Once you set up an account through your state-run Exchange, it’s likely that you won’t have to go back to

If your Exchange is federally facilitated, you will use to complete the plan comparison and application process.

Find my Exchange

Find Assistance
Even after you’ve successfully found your state’s Exchange and are beginning to compare options, you may still have additional questions. There are a few different ways to get connected with consumer representatives.

Online Chat
Visit the online chat feature and interact directly with a consumer representative to get your questions answered in real time.

Local and Regional Assistance
Visit and enter your ZIP code. The search tool will populate a list of organizations in your area with trained Navigators and Certified Application Counselors who can walk you through the entire application process from start to finish. These groups will likely have a better understanding of the plan options specific to your area and may also be able to help you fill out an application for coverage. Hotline
If there are additional issues with the website or if you’d rather speak directly with a consumer representative, there is a toll-free hotline available 24 hours a day, 7 days a week: 1-800-318-2596. Hotline representatives are also available to help you complete the application process over the phone.

Additional Resources
PAN has also developed and collected a number of tools and resources to help answer your questions on issues related to the Affordable Care Act, including the Health Insurance Exchanges.

Visit our ACA Resources page to learn more.

Medicare and Medicaid

   How will the ACA and new Health Care Exchanges affect my Medicare coverage? 

Here’s some good news: it won’t at least not negatively. The ACA doesn’t affect your Medicare choices, and your benefits won’t be changing. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan, you’ll still have access to the same benefits that you have now. The Medicare open enrollment period (October 15 – December 7) will also remain the same. 

In fact, the ACA has already enhanced a number of Medicare benefits, including:

  • Providing seniors who reach the coverage gap (“donut hole”) with a 50% discount when buying Medicare Part D covered brand-name prescription drugs
  • Providing certain free preventive services, such as annual wellness visits and personalized prevention plans, for seniors

You also do not have to worry about enrolling in coverage through your state’s Health Care Exchange. Medicare qualifies as health care coverage under the ACA and isn’t part of the Health Insurance Marketplace. If you have health care coverage through Medicare, you don’t need to do anything.

2.   How will the ACA and new Health Care Exchanges affect Medicare supplemental health insurance

It won’t. The Health Insurance Exchanges will not offer Medicare supplemental (Medigap) insurance. If you currently have Medigap coverage and would like to continue you coverage, the process for doing so hasn’t changed.

In fact, the ACA largely leaves the treatment of Medigap plans unaffected. The ACA originally mandated that certain Medigap plans add nominal cost-sharing by 2015, but the federal government decided to waive this requirement.

Medigap insurance, sold by private companies, is designed to help pay some of the health care costs that traditional Medicare doesn't cover, like copayments, coinsurance, and deductibles. Some Medigap policies also offer coverage for additional services not covered by Medicare, including medical care when you travel outside the U.S. If you have Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then your Medigap policy pays its share. 

It’s important to note that a Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Medicare benefits. 

If you’re interested in learning more about Medicare supplemental (Medigap) coverage, visit for the latest information tailored to your specific needs.

3.   Didn’t the ACA require expansion of Medicaid services to qualifying adults? My state claims it
      has opted out of expansion.

Originally – yes – the ACA called for expanding Medicaid services in all 50 states beginning in 2014 to include individuals between the ages of 19 and 65 who meet the following requirements:

  • Income below 133% of the federal poverty line (133% of the federal poverty line for individuals is approximately $15,000)
  • Citizenship and legal residency
  • Not incarcerated
  • Not entitled to Medicare

However, in June 2012, the Supreme Court ruled that states could choose to opt out of the law’s mandate for Medicaid expansion, leaving the decision to participate up to each state government. Currently, 27 states and the District of Columbia are moving toward expanding Medicaid services in 2014 – including 4 states that are considering alternative models – while 23 states are not moving forward with expansion at this time.

View this interactive map to see where your state stands on Medicaid expansion. 

The ACA makes no changes to the current Medicaid eligibility requirements for the aged, blind, disabled, and Social Security Income recipients. 

Visit to learn more about Medicaid coverage benefits and expansion in your state.

4.   How has the ACA impacted Medicare Part D prescription drug coverage?

The good news is that if you have Medicare Part D prescription drug coverage, you should already see some positive changes since the ACA was signed into law in 2010. Prior to that point, and since the Medicare Part D benefit took effect in 2006, enrollees were required to pay 100% of their prescription drug costs after their total spending reached a certain amount until they qualified for “catastrophic” coverage. This coverage gap is commonly referred to as the “donut hole.”
For more information on Medicare Part D coverage, visit
Impact of the ACA
The ACA gradually reduces the amount that Medicare part D enrollees have to pay out of pocket in the coverage gap, virtually eliminating the “donut hole” by 2020. For example, beginning in 2011, Part D enrollees who reached the coverage gap received a 50% discount on the cost of brand-name drugs – and beginning in 2013, additional subsidies are phased-in to further reduce the cost of brand-name medications. For generic drugs, subsidies begin in 2013 to help reduce the out-of-pocket costs for enrollees.
By 2020:
  • For brand-name drugs, Part D enrollees will receive the 50 percent discount from pharmaceutical manufacturers, plus a 25 percent federal subsidy, limiting their out-of-pocket costs in the coverage gap to 25%
  • For generic drugs, 75 percent of their cost in the gap will be subsidized by Medicare, limiting out-of-pocket expenses to 25% for Part D enrollees
Here are helpful charts from the Kaiser Family Foundation that illustrate how costs will be reduced in the coverage gap, effectively eliminating the “donut hole.”
Medicare Part D Coverage Gap Reduced Cost Phase-in Schedule (Kaiser Family Foundation)


5.   What is happening to Medicare Advantage plans under the ACA?

Medicare Advantage plans allow Medicare enrollees to receive their Medicare benefits through private health plans as an alternative to the federally administered traditional Medicare program. Over time, federal payments to Advantage plans have grown significantly in efforts to expand access to private plans and provide extra benefits to enrollees.

As a cost savings measure, the ACA has gradually reduced federal payments to Medicare Advantage plans in an effort to bring them closer to the average costs of traditional Medicare. This includes limiting the “rebates,” or the amount of money that the private plans were allowed to keep for maintaining costs below a certain threshold.

Starting in 2014, Medicare Advantage plans will be required to maintain a medical loss ratio, which is the amount of money that must be spent on medical care, of 85%. This restricts the share of federal payments and premiums that Medicare Advantage companies can use for administrative purposes, including profits.

While these changes are designed to ensure that a higher percentage of payments are directed toward services, if you have a Medicare Advantage plan, you may notice modifications to your coverage options. The effect of the reductions in payments is expected to vary regionally and by insurer. Companies offering Medicare Advantage plans may respond to these payment changes in several different ways, depending on the circumstances of the company, the location of their plans, and their historical commitment to the Medicare market. While plans will continue to be required to provide all benefits that are covered by traditional Medicare, they may:

  • Charge higher premiums 
  • Increase cost-sharing (Subject to limitations)
  • Reduce their network of providers
  • Reduce "extra benefits” such as dental care or eyeglasses

For more on Medicare Advantage changes in the ACA, please consult this helpful overview from the Kaiser Family Foundation.

6.   What is happening to Medicare Advantage plans under the ACA?

What is the annual “wellness” exam covered by Medicare?

As part of the expanded preventive services for Medicare beneficiaries, in 2011 the ACA established “annual wellness” exams. This is not primarily a physical exam but rather a disease prevention and management visit designed to help you and your doctors identify potential health risks and develop a personalized health management plan.

If you’ve had Medicare B for more than 12 months, the wellness visit is covered completely by Medicare – and Medicare covers one wellness visit per year.

If you haven't yet had an annual wellness exam, check with your primary care physician or neurologist to learn more about how to schedule one.

Once scheduled, your first Medicare wellness visit will have three basic components: acquiring beneficiary history, physical and health maintenance assessment, and medical professional counsel.

1.    Acquiring History

Health Risk Assessment

  • Questionnaire
  • At a minimum, addresses the following topics:
  • Demographic data
  • Self-assessment of health status
  • Psychosocial risks
  • Behavioral risks
  • Activities of daily living (ADLs)
  • Instrumental ADLs

Beneficiary’s Personal and Family Medical History
At a minimum, the following information is collected and documented:

  • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments
  • Use of or exposure to medications and supplements, including calcium and vitamins
  • Major medical events of your parents and any siblings and children, including diseases that may be hereditary or place you at increased risk

Depression Assessment

  • Your doctor will select from various available standardized screening tests to assess individuals without a current diagnosis of depression
  • If you have a current or past depression diagnosis, the doctor will review treatment and management options

Review of Functional Ability and Safety
Your doctor then, through direct observation or any appropriate, standardized screening questions or a screening questionnaire, will assess at a minimum the following topics:

  • Hearing impairment
  • Ability to successfully perform ADLs
  • Fall risk
  • Home safety

2.    Physical and Health Maintenance Assessment

Routine Measurements
The following measurements will be recorded:

  • Height, weight, body mass index (or waist circumference, if appropriate)
  • Blood pressure
  • Other routine measurements as deemed appropriate, based on medical and family history

Providers and Suppliers Assessment

  • Your doctor will make note of the current providers and suppliers that are regularly involved in providing medical care to you

Cognitive Impairment Screening

  • Your doctor will assess your cognitive function, taking into consideration information from outside patient reports and concerns raised by family members, friends, caretakers, or others

3.    Counsel

After the screenings and assessments are completed, you and your doctor will talk through an organized health management plan. The plan will include:

  • Written health screening schedule (depression, cancer, heart disease, immunizations, etc.)
  • List of potential health risk factors for the beneficiary to manage
  • Personal health plan to help the beneficiary manage risk factors, maintain health, and if necessary, to provide referrals to specialists

Each year following your initial visit, your doctor will go through many of the same steps above to reassess your current health care needs and update your health management plan accordingly.

To learn more about the annual wellness visit, please visit and view this annual wellness visit checklist provided by the Center for Medicare and Medicaid Services.

7.   My Medicare coverage does not include dental benefits. Can I purchase dental insurance
      through my state’s Exchange?

It depends on your state.  Some state run Exchanges do have standalone dental plan choices for Medicare beneficiaries, but if your state’s Exchange is facilitated by the federal government, dental plans are currently only available to those who are also purchasing private health insurance. (Find your Exchange)
Even if your state-run Exchange offers standalone dental plans, there are a few things to consider before deciding to purchase through the Exchange. The standalone dental plans for adults can set annual dollar limits on coverage and don’t have to comply with the same caps on out-of-pocket spending that are in place for health insurance plans. Premium subsidies and assistance with out-of-pocket expenses are not available – and in some states, Exchange dental plans may reject adult applicants because of pre-existing conditions.
The choices vary dramatically by state. For example, in Maryland, the Maryland Health Connection Exchange offers 20 dental-only policies that seniors who have Medicare can buy, but the state-run Exchange in California currently only offers standalone dental plans for children. Coverage for adults in California may be added next year.
Medicare beneficiaries also retain the option of purchasing standalone dental coverage outside of the Exchanges as in the past.
If you have Medicare Advantage, some plans in your area may offer dental coverage as part of the overall benefits package.  Visit for more information.

8.   I only have Medicare Part A. Will I be required to get any additional coverage? 

Technically speaking, no. Under the ACA, Medicare Part A qualifies as minimum essential health coverage, which means that if you only have Medicare Part A, you don’t have to worry about being penalized for non-coverage or insufficient coverage.

Medicare Part A coverage includes:

  • Hospital care
  • Skilled nursing facility care
  • Nursing home care
  • Hospice
  • Home health services

But, depending on your health care needs – and particularly for people with Parkinson’s – Part A coverage alone may offer not enough coverage to keep your out-of-pocket health care costs manageable.

If you have prescription drug needs, you may want to consider Medicare Part D prescription drug coverage, an outside qualifying plan, or switching to a Medicare Advantage plan if you are eligible.

Talk to your doctor or other health care provider about what services or supplies you need to manage your health, and ask how they are covered under your Medicare plan.

To learn more about Medicare services for which you may be eligible, please visit

9.   I am now on permanent disability and will soon start receiving Social Security
      Disability Insurance (SSDI) payments. I don’t have health insurance and won’t be eligible
      for Medicare for two years because of the waiting period for SSDI payment recipients.
      What are my options to obtain coverage? 

The good news is that you may have a couple of options depending on where you live. Even though you are receiving SSDI payments, you’re still eligible to purchase individual coverage through your state’s Health Insurance Exchange – and if your income is between 100% and 400% of the federal poverty level (about $11,500 to $46,000 per year for an individual in 2013), you may qualify for premium assistance credits to help cover your insurance costs.

You may also be eligible for Medicaid coverage if your state has opted to expand coverage to adults under age 65 with incomes up to 133% of the federal poverty level (about $15,000 for an individual in 2013).

Important note:
If you are receiving premium assistance credits to purchase insurance through your state’s Exchange, once your two-year waiting period ends and you become eligible for Medicare, you will no longer receive those credits. The premium assistance credits may not be used to lower your Medicare premiums.

To learn more about your potential Medicare options, please visit


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Have Additional Questions?

We want hear from you. If you have a question that isn’t covered, let us know! Your feedback will help make this a stronger tool and better inform us of the type of material that is most important to you and the Parkinson’s community.

Please send your questions to Jamie Tucker at [email protected].

PAN will continue to update this FAQ resource regularly and as new information becomes available.

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