When the Patient Protection and Affordable Care Act passed Congress in 2010, it expanded coverage for 47 million uninsured Americans, and that includes expanded coverage for prescription medications.
The U.S. Department of Health and Human Services projects prescription drug spending to increase from $234.1 billion in 2008 to $457.8 billion by 2019 – almost doubling over the 11-year period, due in part to enhanced coverage under PPACA.
According to a 2010 report by the Kaiser Family Foundation, PPACA cites prescription drug coverage as one of the “essential health benefits” mandated for health plans in both state health exchanges and in the benchmark benefit package or benchmark equivalent under Medicaid for newly eligible adults.
Those whose prescription medications are covered by employer-provided healthcare plans under flexible spending accounts, health savings accounts or reimbursement arrangements will experience a few changes when claiming over-the-counter medications on their taxes.
PPACA provides that expenses for OTC drugs or medicines other than insulin, incurred on or after Jan 1, 2011, will only be eligible for reimbursement under a Health Flexible Spending Account, Health Reimbursement Arrangement or Health Savings Account for IRS purposes if they are “prescribed.” OTC medical supplies and equipment – such as contact lens solutions, bandages, crutches, durable medical equipment, or diagnostic devices like blood sugar test kits – may still be purchased under the current process.
Patti Gulager, a local registered nurse who has read the PPACA law in its entirety, said some insurance plans have already begun requiring prescriptions.
“Some plans have been moving to the prescriptions for OTC drugs,” said Gulager. “Our personal health care plan today does, in order [for us to receive the tax benefit]. Medications requiring prescriptions include Prevacid, Zantac, etc.”
Jesse C. Vivian, registered pharmacist and professor of the Department of Pharmacy Practice, College of Pharmacy and Health Services at Wayne State University, in Detroit, believes the overall effects of PPACA should be good for pharmacy providers, in terms of the number of people eligible for prescription benefits.
In a report in uspharmacist.com, Vivian said some group health plans will no longer be able to impose lifetime or annual limits on healthcare expenditures, including prescription drug reimbursements.
“By 2014, no group health plans or group health insurers will be allowed to enforce any annual spending limits on covered employees and dependents, and will be only allowed to impose lifetime benefit limits on nonessential health care spending,” wrote Vivian. “Likewise, insurers cannot rescind specified covered benefits, except in cases of fraud or intentional misrepresentation by a benefit applicant, after they are offered. However, this does not mean employers cannot terminate health plan coverage entirely for employees who are eligible for alternate government-sponsored plans.”
Sen. Tom Coburn, R-Okla., is also a physician who is opposed to PPACA. He believes the law encourages employers to drop coverage for employees, thereby increasing costs to taxpayers.
“[But] there is still time to avoid the loss of high-quality private coverage and subsequent costs to taxpayers,” said Coburn. “Businesses are most likely to start dropping coverage in 2014, the year the biggest insurance changes and employer penalties begin. [I] support repealing the law before 2014, and replacing it with reforms that do not discourage employers from offering coverage and lower costs.”
Gulager believes PPACA will streamline pharmacy services, especially those covered by Medicare.
“Right now, the large number of plans out there are confusion as to [benefit caps],” said Gulager. “The insured also have limits on how much they can obtain in a benefit year. There should be less seen of this in the new design. Right now, lengthy letters of [medical] necessity, as well as charity from drug companies, are needed to provide the needed amounts [of prescription medications to pharmacies]. In the discussions I have heard recently, access to [preventive care] and early detection may keep the need for more of the high-end, [expensive] drugs down overall.”
Effective Aug. 1, PPACA expanded coverage for women, providing a number of services cost-free, including contraception. Many have wondered if certain medications, like Viagra, will now be provided at not cost to men, or if other medications will be excluded. Gulager said the cost of Viagra prohibits the possibility of its being made free to all men.
“I am not aware of any medications that [won’t be covered] under the act,” said Gulager. “When you look at contraceptives being [made available] at no cost, it is very different from Viagra. [Erectile dysfunction] drugs have very tight patents and have been on the market a very short time [compared to contraceptives]. If you look at drugs, in general, you know that the longer they are available and the amount of [competing companies making them] drives the cost down. Since the use of Viagra is considered non-life-sustaining, I wouldn’t look for any changes in the distribution anytime soon.”
Julie Ward, vice president of finance for Tahlequah City Hospital, said while there may be some limitations to specific procedures, she anticipates coverage for all citizens being similar to those provided under Medicare.
“We would anticipate those who are covered will have benefits similar to Medicare, with the same pre- and post-screening processes to ensure adequate physician and hospital documentation, the physician identifying the required codes, and correctly determining the required status of the patient,” Ward said. “If the physician is not completely compliant with these regulations, the hospital’s reimbursement is negatively impacted.”
TCH offers counseling on covered insurance benefits, but Ward said patients have a responsibility to educate themselves about coverage.
“We have invested significant resources into the patent access process to ensure our patients get all of their needs met,” said Ward. “We also believe insurance companies have a duty and a responsibility to educate their customers on their benefits. Our experience is that Medicare communicates fairly well with their customers. Finally, the patient has a responsibility to learn what benefits they are entitled to.”
Gulager believes PPACA provides expanded opportunity for physicians and clinics to expand their practices, as well as improving outcomes for patients overall.
“The access should be easier for getting the medications you need, and especially pleasing to me is the pediatric component,” said Gulager. “So many children are going to get the medications they need in a timely manner. Hopefully, families won’t have to make the choice between buying medication for a child or food for the family.
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