In March 2010, the Patient Protection and Affordable Care Act, often called health care reform, was signed into law, changing several rules regarding health care insurance coverage in the United States. For people with cancer, this new law affects both the cost of and access to medical care. Highlights of the new law are summarized below, many of which took effect January 1, 2014, unless otherwise noted.
This list is not intended to be a complete summary of the new law; instead it is meant to provide an overview of major areas of health reform that relate to the cost of and access to cancer care. More details can be found on the federal government's website, www.HealthCare.gov.
General health 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, which means an insurance company can’t refuse to cover a person’s health care for the rest of the person’s life once a specific dollar amount is reached.
- Additionally, the law prohibits new plans and existing group plans from imposing annual dollar limits on most covered benefits (this does apply to non-essential benefits). This means that insurance companies cannot refuse to pay for care after you have reached a specific dollar amount for that year for any benefits that are covered. You may still be responsible for paying for benefits that are not covered under your plan.
- 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.
- Adults and dependent children under age 19 cannot be denied coverage for pre-existing conditions. There may be exceptions for people covered under grandfathered individual plans.
- In the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates because a patient is male or female or has a specific health condition.
- For plans that start on or after January 1, 2014, waiting periods for coverage greater than 90 days will be prohibited from group health plans.
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. Penalties for people who can afford health insurance but do not obtain it will be phased in beginning in 2014.
- Individuals without insurance will be able to purchase insurance from the health insurance marketplace (insurance exchanges). These exchanges will 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 (in 2013, $45,960 for individuals and $94,200 for a family of four).
- 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.
- In 2012, the Supreme Court ruled that a state has the option of whether to expand Medicaid coverage to individuals with incomes up to 133% of the federal poverty level who are under 65 and are not otherwise eligible for Medicare. (In 2013, this amount was approximately $15,282 for an individual and $31,322 for a family of four.)
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 cost sharing for preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) including but not limited to:
- Screening tests for colorectal cancer for people between the ages of 50 and 75.
- Mammograms for women over 40 every one to two years. Other services to prevent breast cancer will also be covered, including a referral to genetic counseling and a discussion of chemoprevention for some 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 some types of 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 has also been eliminated.
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.
For people participating in clinical trials
For plans beginning on or after January 1, 2014 insurers will not be allowed to limit or drop coverage to an individual choosing to participate in a clinical trial. Grandfathered health plans are not required to comply with this requirement. This applies to clinical trials to treat cancer, in addition to other life-threatening diseases.