Insurance and Affordable Care Act

Find out how to get the insurance you need for your adult heart condition

Having Insurance

Having good health insurance is important—especially if you have congenital heart disease. With the passage of the Affordable Care Act (ACA) in 2010, every American can get health insurance and, in fact, must have it or pay a tax penalty.

One very important feature of the ACA is that you cannot be denied insurance because of a pre-existing condition—including heart defects.

Other key parts of the act require that:

  • Young adults can stay on their parents’ insurance plan until age 26
  • Insurers cannot cancel your plan if you get sick or make an honest mistake
  • There are no lifetime or annual limits or caps on most health benefits
  • You cannot be charged more based on your health status or gender
  • Prevention services are free. You do not pay extra for them
  • Adults receiving Medicare under Part D prescriptions drug coverage, “the donut hole,” will receive a 50% discount on all brand name drugs

Getting Insurance

There are four ways to get insurance:

  1. Through your job if it is available
  2. Through a state Health Insurance Marketplace. As of 2016, approximately 20 states have some form of state-based marketplace. You can find out more about state-based marketplaces on healthcare.gov
  3. Through the federally facilitated Marketplace if your state does not have a Marketplace, also accessible on healthcare.gov
  4. Through the expansion of Medicaid

When you go to these sites, you will be asked a number of questions about your health and economic status. In some cases, you will be eligible for a subsidy or tax credit to help pay for your insurance.

Level of Benefits

The Marketplace is a one-stop place where you can compare plans, choose one that works for you and enroll. The costs and benefits of the plans can vary widely, so take the time to find the plan that fits your heart condition and your life and allows you to see an ACHD specialist.

Every plan offered either by your job or through the Health Insurance Marketplace must include basic and essential health benefits.

  • Outpatient care and doctor’s visits
  • Emergency room care
  • Hospitalization including surgery
  • Care before and after the birth of a baby
  • Mental health and substance abuse care
  • Prescription medicines
  • Services and devices for people who are injured or have health conditions
  • Lab tests
  • Preventive services
  • Healthcare for children, including dental and eye care

NOTE: “Included” does not always mean fully paid for. There are often deductibles, co-pays and charges for “covered” services and procedures. These can be significant. Ask questions and understand your policy.

You can also choose levels of benefits, often ranked from Platinum for the highest level of coverage to Silver or Bronze for lower levels. Higher levels of coverage mean higher premiums but more extensive coverage, while lower level coverage is less expensive upfront but can often leave you with significant costs if you get sick or are hospitalized.

As a congenital heart patient, it is critical to look carefully at the different options and pick a policy that meets your needs. Make sure your ACHD specialist and ACHD clinic are part of the network. This is a very individual choice for people with congenital heart disease.

Signing Up for Insurance

There is an open enrollment period for health insurance that varies each year.  To receive information about future open enrollment periods, sign up for emails at www.healthcare.gov. You can also sign up at other times if your job, insurance or health status changes.

To learn more go to www.healthcare.gov. If you have problems with online enrollment, you can also apply by phone. There are people available to help you, answer your questions and guide you through the enrollment process.

Phone 1-800-318-2596

Get Organized

Before you apply, make sure you have:

  1. Your Social Security number
  2. Employer and income information from your W-2 form, current pay stubs or your most recent tax return
  3. The policy number of any current insurance plan you have
  4. A completed Employer Coverage Tool, which you will find on your Marketplace

You should think about your budget for healthcare and your specific healthcare needs before you complete your enrollment.

Write down your questions. Don’t hesitate to ask them. Stay informed.

Want to Learn More?

Additional information about insurance and related matters is available at these resources:

Patient Advocate Foundation
Information and education to assist patients with access to care, medical debt, and job retention issues related to their illness, including co-pay assistance

A Consumer's Glossary of Insurance Terms
A-Z glossary of insurance-related terms

Healthinsurance.org
Consumer information on affordable health and medical coverage

HealthWell Foundation
Assistance with co-payments and premiums

Patient Access Network Foundation
A nonprofit 501(c)(3) organization dedicated to supporting the needs of patients that cannot access the treatments they need due to out-of-pocket health care costs

Patient Services Inc.
A nonprofit that assists patient with chronic illnesses in meeting their co-pays and premiums