The Affordable Care Act and Cancer

Approved by the Cancer.Net Editorial Board, 11/2018

The Patient Protection and Affordable Care Act is a law about health care. People call it “health care reform” or the ACA. This law passed in March 2010. It changed several health insurance rules in the United States.

The information below tells you some important ways the ACA currently affects cancer care. You can learn more from the ACA website.

If you do not have health insurance

The Affordable Care Act says most U.S. citizens and legal residents must have health insurance. For the 2018 tax year, people who can afford health insurance but do not buy it will be charged a fee. An exemption may be granted for:

  • Financial hardships

  • Religious objections

  • Undocumented immigrants

  • People in jail

  • People who are Native Americans

  • People without health insurance coverage for less than 3 months

  • People for whom the lowest cost plan option is more than 8% of their income

  • People who have incomes that are so low they do not file taxes

Other things you should know are:

  • You may buy insurance from the health insurance marketplace. Another name is the “insurance exchange.” It helps people and small businesses get insurance.

  • You can get help paying for insurance if you earn less than a certain amount. Right now, this is $47,080 or less for 1 person. For a family of 4, it is $97,000.

  • You might be able to get Medicaid from your state. Some states give Medicaid to adults who earn $16,654 or less for 1 person or $32,252 for a family of 4.

General information on the ACA

Below are some general rules about the ACA:

  • You cannot be denied insurance because of a condition you had before you applied for insurance. Your insurance company also cannot refuse to pay for a condition you had before you got insurance. Companies call this a “pre-existing” condition. They must pay unless a special rule says they do not have to.

  • Your health insurance company cannot charge more because you are female, male, or have a specific health condition.

  • If you join a group insurance plan, you get benefits in 90 days or less. This means the company starts paying within this time. Group plans include many people. For example, health insurance from work is usually a group plan. This rule started on January 1, 2014.

  • Private insurance companies cannot limit how much they pay for care in your lifetime. In the past, they could stop paying after a certain amount. But most cancer care is expensive. Some people had to pay for all their care after the coverage stopped. Now, your insurance company must keep paying for care. This is true even if you need a lot of care, such as for cancer.

  • Your insurance company cannot stop paying its part of your bills. This is true unless you or someone else commits fraud (cheating).

  • A company cannot cancel your insurance if they find a mistake in your application.

  • If the plan covers your children, your children can use it until they turn 26.

  • Adults and children younger than 19 cannot be denied coverage for pre-existing conditions. There may be exceptions for people covered under "grandfathered" individual plans, which means the health plan existed when the ACA was signed into law.

  • In the individual and small group market, insurance companies cannot charge higher rates based on a person's gender or specific health condition.

You pay nothing for some tests and services

Some tests and services can lower your cancer risk. So the Affordable Care Act says health insurance must pay for them. The U.S. Preventive Services Task Force recommends these services. They include:

  • Colorectal cancer screening tests if you are 50 to 75

  • Mammograms every year or 2 for women over 40. Companies must also pay for some other services to prevent breast cancer. For example, women with a higher risk of breast cancer can:

    • See a genetic counselor to talk about breast cancer risk

    • Talk to a doctor about medication to prevent breast cancer

  • Regular screening for cervical cancer and the HPV vaccine to prevent cervical cancer.

  • Help to stop smoking, such as counseling and medication.

If you ask your insurance company to pay

When your insurance company says they will not pay, you can ask again. For example, you might write a letter. Or, your doctor might write one. This is called an “appeal.”

If your plan started by July 1, 2011, the company must answer your appeal within a certain time. This is:

  • 72 hours after you send an appeal for urgent medical care

  • 30 days for non-urgent care, if you did not get it yet

  • 60 days for care you already received

If the company says no, you can ask another company to review their decision. This is called “external review.” Your company must pay if the external review says so.

If you are in a clinical trial

Clinical trials are research studies involving volunteers. Most insurance companies cannot limit what they pay if you are in a clinical trial. They must pay for all of the health care services related to the clinical trial. This is true for insurance starting January 1, 2014, or later. Also, your company cannot stop your insurance if you are in a clinical trial. Doing this is called “dropping” your coverage.

If your insurance started before January 1, 2014, the company can limit what it pays if you join a clinical trial. It can also stop paying for your health care.

If you have questions about your insurance coverage, talk with your health care team or an insurance company representative before treatment begins.

Related Resources

Health Insurance

Risk Factors and Prevention

Clinical Trials

Health Insurance Coverage of Clinical Trials

More Information

Kaiser Family Foundation: Health Insurance Marketplace Calculator