The Affordable Care Act’s Patient Protections
The Affordable Care Act requires health insurance plans sold through www.healthcare.gov and its state-based marketplaces to comply with a number of requirements. Many of these – including the ones described below – are meant to ensure that patients have access to meaningful health insurance coverage. It’s important to be aware that some health plans, available today through non-governmental sites, may not include these patient protections.
Pre-existing conditions: Health insurers selling coverage through the marketplace may not refuse to enroll children or adults due to pre-existing medical conditions like cancer. Health insurers must also cover treatment for any pre-existing conditions starting on Day 1 of your new health insurance plan.
Rescissions (plan cancellations): In the past, health insurers could cancel coverage due to an error or technical mistake in a person’s health insurance application. The Affordable Care Act made this practice illegal. Now, insurers may cancel or “rescind” your plan only if you commit fraud, intentionally lied on your application, or stop paying your premiums.
Premium rating: Health insurers cannot change your premiums based on a pre-existing medical condition, health history, or gender. The Affordable Care Act permits insurers to adjust premiums based only on age, geographic location, and (in some states) tobacco use.
Annual or lifetime limits: Health insurers cannot set annual or lifetime limits (sometimes known as “caps”) on how much they will pay for the benefits that are covered by your plan. You may still be responsible for paying a portion of the cost of your care.
Purchasing Coverage through the Marketplace
The Affordable Care Act created the health insurance marketplace to facilitate access to coverage for individuals and certain small businesses. Every plan sold through the marketplace must meet a number of requirements. This includes covering a minimum set of benefits and following the federal government’s limit for the amount of costs that the plan may require the consumer to cover.
Depending on your household income, you may be eligible for an “advance premium tax credit,” or “APTC,” to help lower the cost of your premiums. APTC amounts are much higher this year than in previous years and there is no longer a hard income cutoff. If your household income meets certain other standards, you may be able to purchase a “Silver” plan that has lower out-of-pocket costs in addition to lower premiums.
It is important to keep in mind that only plans sold through www.healthcare.gov and the authorized marketplace for your state are authorized to offer these potential cost savings. These plans are also guaranteed to include the patient protections described above. There are many other kinds of products for sale that might be called “health insurance” but which might not include the patient protections that are critical to cancer care. This can include, for example, “short-term limited-duration” plans, Farm Bureau plans, healthcare sharing ministries, and association health plans. When in doubt, or when a deal seems too good to be true, check www.healthcare.gov or call your state’s marketplace or department of insurance to ask for assistance.
The Marketplace can also help you determine if you or members of your family may be eligible for Medicaid. You can enroll in Medicaid anytime through the year, if you're eligible.
Open enrollment runs from November 1, 2021 to January 15, 2022 federally and in most states, though some states stop at December 15th. It is important to comparison-shop for your health insurance coverage every year. Even if you like the plan you have, it might be worthwhile to assess whether one of the options available this year are better suited to your current needs.
While you’re shopping for coverage, it’s important to remember that premiums are just one piece of the total cost of any health insurance plan. Typically, plans will also require you to pay “cost-sharing.” This means having to pay out of your own pocket to cover a portion of the total cost of your care. Cost-sharing might include copays, deductibles, and coinsurance. Cost-sharing amounts can vary greatly between plans, which is why it’s important to pay close attention to those details when shopping for coverage.
Some plans can have very high deductibles. A deductible is the amount of money you must pay out-of-pocket before your plan will begin paying for your care. Depending on the plan, this could mean you have to pay the full cost of certain office visits, specialty services, or prescription drugs until you’ve met your deductible.
Sometimes a plan will use “coinsurance.” Coinsurance means that instead of paying a flat dollar amount (like a copay), you will pay a percentage of the total cost of a drug or service, and the plan will pay the rest. For some cancer medications, this can translate to hundreds or even thousands of dollars for one month’s supply of that drug.
When it comes to prescription drugs, it’s equally important to compare plans carefully. Every plan has a list of drugs that it will cover, called a “formulary.” Make sure that your drugs are listed on the formulary for the plan you’re considering, and be sure to review the cost-sharing assigned to those drugs.
The Affordable Care Act sets limits on the total amount that you will have to pay in out-of-pocket costs over the course of the year. In 2022, that limit is $8,700 for an individual and $17,400 across all family members who share a plan. Some plans will have lower limits, but no plan can have higher out-of-pocket costs than these amounts. It is important to remember that this limit does not include certain costs, such as premiums, most out-of-network medical care, and services and medications that aren’t already covered or approved by your plan.
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If you have questions or want more information, please contact an LLS Information Specialist.
- Blood Cancer Patients’ Frequently Asked Questions about the Affordable Care Act
- From the Kaiser Family Foundation: 300 Answers about the Affordable Care Act
- Get Help with Your Health Insurance Application
- Download or order The Leukemia & Lymphoma Society’s free booklet, Cancer and Your Finances