The Affordable Care Act: An Overview of the Consumer Protections

The cancer community has benefited tremendously from the Patient Protection and Affordable Care Act (ACA).  As we have talked about in the past, the ACA is a complex law effecting multiple aspects of health care in this country.  One of the most important things the law has done is create new protections for all of us as consumers of health care.  We thought that it was important to review and highlight some of those consumer protections that apply now, regardless of where someone gets their health insurance: though the ACA Marketplaces, from an employer, or directly from a health insurance company.

  • Insurance companies can’t cancel your policy if you get sick or make a mistake on your application. In the past, insurance companies would cancel someone’s policy once they got sick under the claiming that they weren’t honest in their original applications, even if it was a simple mistake or omission.  Needless to say, a cancer diagnosis was a prime reason to rescind someone’s policy.  Now, insurance companies can only cancel your policy if they can show you committed fraud or intentionally lied about something important.
  • No annual or lifetime dollar limits on essential health benefits. For a cancer patient this means your insurance will be there for your entire cancer journey – from diagnosis to survivorship – even if that journey takes years or costs thousands of dollars.
  • Access to certain preventative services for free – meaning that these services are covered at 100%, even before you reach your deductible and without any co-payments.  Covered services include genetic testing, mammography screening and colon polyp removal.
  • All major medical insurance is guaranteed issue, meaning you can’t be denied coverage for any reason. Insurance companies used to take into consideration someone’s health status to determine if they would sell them coverage and how much they would charge for that coverage. Cancer was often a deal breaker.  It either meant extremely expensive coverage or no coverage all.  Since January 1, 2014, insurance companies can’t deny you coverage and you are free to change plans yearly.  This means cancer patients are able to take time off work for treatment and recovery or to change jobs, without the fear that they will never get insurance again.
  • You can’t be charged more based on health status or gender.  In the past, a cancer diagnosis often meant a significant increase in your premium.  And if you had a diagnosis like ovarian cancer, you would have been hit doubly hard because you were a woman with cancer.  Now, insurance companies are only allowed to consider four things when they are determining how much they are going to charge you: if you are buying an individual or a family plan, your geographic location, your age, if you use tobacco.
  • You have the right to get an easy-to-understand summary about a health plan’s benefits and coverage, called a summary of benefits and coverage (SBC).  This is critical for consumers to understand exactly what it is they are buying!
  • Health Insurance Marketplaces allow shoppers to compare health insurance plans that offer minimum essential coverage and include all new benefits, rights and protections of the law. Minimum essential coverage includes:
  1. Ambulatory patient services (outpatient care)
  2. Emergency Services (trips to the emergency room)
  3. Hospitalization (treatment in the hospital for inpatient care)
  4. Maternity and newborn care
  5. Mental health services and addiction treatment
  6. Prescription drugs
  7. Rehabilitative services and devices
  8. Laboratory services
  9. Preventive services, wellness services, and chronic disease treatment
  10. Pediatric services
  • Financial assistance is available to individuals, families and small businesses through the state Health Insurance Marketplaces.  There are two types of financial assistance: a premium tax credit and a cost sharing subsidy.  Eligibility for this assistance is based on family size and income level.  When entering the world of cancer treatment, the costs are overwhelming, and frankly almost impossible to handle without insurance.
  • The 80/20 rule and rate review provision help to keep insurers honest and keep rates down.  This rule means that most insurance providers must spend 80% of every dollar they take in on paying for claims and/or improvement in services and can only spend 20% on marketing and overhead costs.
  • You have the right to appeal any health insurance company decision. Under ACA and some state laws, you not only have the right to appeal a decision internally with your insurance plan, but you also have the right to ask for an external review.  This means that an external, independent, specialist will review your appeal and the insurance plan no longer has final say over whether to pay a claim.

None of these consumer protections existed prior to the ACA.  While we at Triage Cancer are the first to acknowledge that there are still many ways to improve our health care system, we are disheartened to think that we may be sent back to the days where a cancer diagnosis or having another serious medical condition may force you into bankruptcy, homelessness, or even not being able to get medical care.  The President-elect and congressional leaders have made numerous statements about their desires to “repeal and replace” the ACA.  While there isn’t a consensus as to what that looks like yet, you can read more about the possibilities being discussed here.

It is sometimes hard to remember how far we have come, but we only want to look forward, at how we can continue to improve the lives of those touched by cancer, and the rest of our country.

And you can help us do that.

  • Even though the election is over, as citizens, we still have a say in how our government is run. It is time to organize, mobilize, and advocate for the cancer community. Call or email your elected officials and tell them what the ACA means to you. Tell your story! To find your elected officials or learn more about becoming an advocate, visit our Advocacy resources page.
  • Communicate with your elected officials about your health insurance concerns. You can find the Facebook and Twitter handles for the current members of Congress here.
  • Share your story with Families USA or the National Coalition of Cancer Survivorship (NCCS), two health care advocacy organizations. Both organizations have pledged to work to help our elected officials understand the dire consequences of repealing the ACA and how certain changes to our health care system can impact us all. But they need the stories of real people who will be impacted by the ACA’s repeal. If you feel comfortable doing so, you can share your story at http://familiesusa.org/share-your-story or at http://www.canceradvocacy.org/blog/share-your-aca-story/.

We also want to remind you that change is Washington is rarely swift and that we may not see changes for most of 2017.  That means that we have to continue to operate with the system we have for now and ensure that people have health insurance coverage for 2017.  If you do not have health insurance coverage, you can apply for Medicaid at any time or purchase a policy through the State Health Insurance Marketplaces until January 31, 2017. If you want your policy to begin on January 1, 2017, you need to have picked a plan by December 15, 2016.  For more information about how to choose a health insurance policy (including making choices between employer-sponsored options), watch our recorded webinar. If you aren’t sure what your health insurance options are, our recently released toolkit, Finances 101, may be useful.

Stay tuned to our Blog and sign up for our newsletter, will continue to provide updates as more information becomes available in the coming months.