Cancer and the Affordable Care Act

Approved by the Cancer.Net Editorial Board, 06/2015

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 law affects both the cost of and access to medical care. A summary of the highlights of the law are listed below.

This list is not meant to be a complete summary of the law. Instead, it is provides an overview of major areas of health reform that relate to the cost of and access to cancer care. Find more details on the federal government's website,

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. This 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.

  • The law bans new plans and existing group plans from charging annual dollar limits on most covered 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 cancel 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.

  • Insurers cannot deny coverage for pre-existing conditions, unless they are grandfathered individual health 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 started on or after January 1, 2014, waiting periods for coverage greater than 90 days are prohibited for group health plans.

For people without health insurance

  • Most U.S. citizens and legal residents are required to have health insurance. Penalties for people who can afford health insurance but do not obtain it began in 2014. The exemptions  to the requirement to obtain health insurance that may be granted include:

    • The person has financial hardship

    • The person has religious objections

    • The person is a member of a federally recognized tribe or eligible for services through an Indian Health Services provider

    • The person has been uninsured for no more than two months

    • The person is in jail

    • The lowest cost plan option is more than 8.05% of the person’s income

    • The person has an income below the tax filing threshold

  • Individuals without insurance can purchase insurance from the health insurance marketplace (insurance exchanges). These exchanges can help people and small businesses with the purchase of coverage. Premium and cost-sharing credits are available to individuals and families earning up to 400% of the federal poverty level (In 2015, the numbers are $46,680 for individuals and $95,400 for a family of four). Individuals can find information about their health insurance options in a standardized format at

  • In 2012, the United States Supreme Court ruled that a state has the option of whether to expand Medicaid coverage to adults with incomes up to 133% of the federal poverty level who are under 65 and are not otherwise eligible for Medicare. (In 2015, this amount is approximately $16,243 for an individual and $33,465 for a family of four).

Elimination of co-pays for preventive services

To increase access and use of tests and services that can lower a person’s cancer risk, the Affordable Care Act requires that certain preventive services recommended by the U.S. Preventive Services Task Force (USPSTF)  are provided without patient cost-sharing by private health insurance plans. These services include but are 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 are also covered, including a referral to genetic counseling and a discussion of chemoprevention for some women at increased risk.

  • Regular Pap smear tests to screen for cervical cancer and the HPV vaccine, which can prevent cervical cancer.

  • Tobacco cessation interventions, such as counseling or some types of medication to help individuals quit smoking.

There are no longer required co-pays for Medicare-covered preventive services recommended by the USPSTF with a grade of “A” or “B”.  

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

  • 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 that began on or after January 1, 2014, insurers will not be allowed to limit or drop coverage for 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.

More Information

Health Insurance

Risk Factors and Prevention

Clinical Trials

Health Insurance Coverage of Clinical Trials

Additional Resources

USPSTF Consumer Information