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In March 2010, the Patient Protection and Affordable Care Act - often called simply Health Reform - was signed into law, changing several rules regarding health care insurance coverage in the United States. For people with cancer, this new law covers areas regarding both the cost of and access to care. Some changes took effect immediately, and others will take effect in the coming years. Highlights of the new law are summarized below and are adapted from information from the Kaiser Family Foundation, unless otherwise noted. This list is not intended to be a complete outline, but rather is meant to provide an overview of major areas of health reform relating to the cost of and access to cancer care. More details can be found at the federal government's website of www.HealthCare.gov.
How Does Health Reform Help You Now?
General Insurance Reform
- Private health plans are not allowed to place a lifetime limit (called a cap) on the dollar value of a person's coverage. Subject to certain restrictions, insurers are permitted to place an annual limit on the dollar value of coverage until January 1, 2014, but will not be permitted to enforce annual limits after that date.
- Insurers cannot take away coverage except in cases of fraud. Previously, insurance companies could revoke coverage for an error or technical mistake in a patient's insurance application. This practice is now illegal.
- Insurance plans that offer dependent coverage are now required to make coverage available to adult children up to age 26 (although certain “grandfathered” group health plans may exclude such coverage if the adult child is eligible to enroll in a health plan through his or her own employer).
- Dependent children under age 19 cannot be denied coverage for pre-existing conditions.
For People Without Health Insurance
- Uninsured individuals with pre-existing medical conditions now have access to a temporary national high-risk insurance pool program. U.S. citizens and legal immigrants who have been uninsured for at least six months are able to enroll for coverage through this high-risk pool and receive subsidized premiums. (Effective until January 1, 2014.)
- States must establish a website to help residents identify coverage options in a standardized format. This includes the federal government's HealthCare.gov website, which provides information on the new law and insurance options for consumers.
Elimination of Co-pays for Preventive Services
Cancer prevention and risk-reduction strategies can lower the physical, emotional, and financial burden of cancer and improve the overall health of cancer survivors, including reducing the risk of the cancer coming back or the chance of a second cancer. The new law includes several provisions to increase access to cancer prevention services:
- Private health insurance plans issued after September 23, 2010, are required to eliminate co-pays for preventive services recommended by the U.S. Preventive Services Task Force (USPSTF; www.uspreventiveservicestaskforce.org) including but not limited to:
- Screening tests for colon cancer for adults over 50.
- Annual mammograms for women over 40. Other services to prevent breast cancer will also be covered, including a referral to genetic counseling and a discussion of chemoprevention for certain women at increased risk.
- Regular Pap tests to screen for cervical cancer and coverage for the HPV vaccine, which can prevent cervical cancer.
- Tobacco cessation interventions, such as counseling or medication to help individuals quit smoking.
- Co-pays for Medicare-covered preventive services recommended by the USPSTF have been eliminated. The Medicare deductible for colorectal cancer screening tests have also been eliminated. Both changes were effective January 1, 2011.
Appealing Health Plan Decisions
- Beginning with plan years starting after July 1, 2011, insurance companies that deny payment for a treatment or service are required to conduct internal appeals at the patient's request within specific timelines: 72 hours after receiving an appeal for urgent medical care; 30 days for non-urgent care you have not yet received; and 60 days for services you have already received. If after the internal appeal, you are still denied coverage, you have the right to request an independent external review. If the external review overturns the denial of services, your insurance company is required to cover the payment or services requested in your claim.
How Will Health Reform Help You in the Future?
General Insurance Reform
- Adults cannot be denied coverage for pre-existing conditions. (Effective January 1, 2014.)
- Waiting periods for coverage greater than 90 days will be eliminated by January 1, 2014.
For People Without Health Insurance
- Most U.S. citizens and legal residents will be required to have health insurance beginning in 2014. Exemptions can be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, people in jail, people for whom the lowest cost plan option exceeds 8% of an individual's income, and those with incomes below the tax filing threshold. (In 2011, the threshold for taxpayers under age 65 was $9,500 for singles and $19,000 for couples.) Penalties for not having health insurance will be phased in beginning in 2014.
- Medicaid coverage will be expanded to individuals with incomes up to 133% of the federal poverty level who are under 65 and who are not otherwise eligible for Medicare. (The poverty level was $18,530 for a family of three in 2011.) (Effective January 1, 2014.)
- State-based health insurance exchanges will be established to help people and small businesses with the purchase of coverage. Premium and cost-sharing credits will be available to individuals and families earning up to 400% of the federal poverty level. The Office of Personnel Management, a federal government agency, will begin contracts with health insurance providers to offer at least two multi-state plans in each exchange. (Effective January 1, 2014.)
Elimination of Co-Pays for Preventive Services
- Co-pays for Medicaid-covered preventive services recommended by the USPSTF will be eliminated, effective January 1, 2013.
For Individuals Participating in Clinical Trials
- As of January 1, 2014, insurers will not be allowed to limit or drop coverage to an individual choosing to participate in a clinical trial. This applies to clinical trials to treat cancer, in addition to other life-threatening diseases.
The next section offers a list of questions in different categories for you to ask while planning for your financial future.
U.S. Government's website on health reform law: www.HealthCare.gov