Protections under the ACA: Cancer

According to the National Cancer Institute, an estimated 1,735,350 new cases of cancer will be diagnosed in the United States and 609,640 people will die from the disease this year. In 2016, there were an estimated 15.5 million cancer survivors in the United States. The number of cancer survivors is expected to increase to 20.3 million by 2026. Before the ACA, cancer survivors could be denied health coverage based on their pre-existing condition. Thankfully, the Affordable Care Act (ACA) has changed that.

The ACA has provided numerous benefits for people with pre-existing conditions especially the cancer community. One of the significant benefits of the law— it created new protections for all of us as consumers of healthcare. Since cancer is one of the leading causes of death, we thought that it was important to review and highlight some of those protections that the ACA provides to everyone including cancer patients and survivors.

Consumer protections in all ACA Marketplace plans

The ACA created these consumer protections for all ACA Marketplace plans, and in many instances, this pertains to any insurance from an employer or coverage directly from a health insurance company.

• Everyone has access to certain preventive services, free of cost. Meaning, these services are covered at 100%, even before you reach your deductible and without any co-payments.  Covered preventive services include colorectal cancer screenings, cervical cancer screenings, mammograms, genetic testing, and help to stop smoking.
• You can’t be denied coverage for any reason—for all individual major medical insurance in all states, an applicant's medical history is no longer a factor in their eligibility for health insurance. Before the ACA, insurance companies considered coverage by someone’s health status. They had the choice to decide if they would sell them coverage and how much they would charge for that coverage. Cancer was often a barrier to coverage. It often meant costly coverage or no coverage at all. Under the ACA, insurance companies can no longer deny you coverage, and you are free to change plans yearly during Open Enrollment. Cancer patients can take time off work for treatment and recovery or to change jobs, without worrying if they will ever get insurance again.
• Insurance companies can’t cancel your policy if you get sick or make a mistake on your application. In the past, insurance companies could cancel someone’s policy once they got sick. A common practice was to often claim that the patient wasn’t honest in their original applications, even if it was a simple mistake or omission. Unfortunately, a cancer diagnosis was a prime reason to cancel someone’s policy. Now, insurance companies can only cancel a policy if they can show that the person committed fraud or intentionally lied about something important.
• There are no annual or lifetime dollar limits on essential health benefits anymore. For cancer patients, costs could be very expensive. With this protection, health insurance will be there for the entire cancer journey – from diagnosis to survivorship – even if that means many years or high costs.
• You can’t be charged more based on health status or gender. Previously, a cancer diagnosis often meant a significant increase in your premium. For example, an ovarian cancer diagnosis meant you could be hit with higher costs because you were a woman with cancer. Now, insurance companies can only consider four things when they are determining how much they are going to charge you: if you are buying an individual or a family plan, your geographic location, your age, and if you use tobacco.
• You have the right to appeal any health insurance company decision and ask for an external review if needed. Under the ACA and some state laws, you have the right to appeal a decision internally with your insurance plan. If necessary, you can request an external review, which means an external, independent specialist will review your appeal, and the insurance plan no longer has final say over whether to pay a claim.
• The ACA includes an 80/20 rule and rate review provision that helps to keep insurers honest and keep rates down. This rule means that most insurance providers must spend 80% of every dollar they take in on paying for claims and/or improvement in services and can only spend 20% on marketing and overhead costs.

Additional consumer protections under the ACA

• Financial assistance is available to individuals, families and small businesses through the Healthcare Marketplace. There are two types of financial assistance: a premium tax credit and a cost-sharing reduction. Eligibility for this assistance is based on family size and income level. Cancer treatment can be very expensive, and the costs may be overwhelming, without insurance it could be impossible to handle.
• You are entitled to an easy-to-understand summary about a health plan’s benefits and coverage called a summary of benefits and coverage (SBC). This is critical for consumers to understand what it is they are buying and if the information is correct.
• The healthcare Marketplace allows shoppers to compare health insurance plans that offer minimum essential coverage. Minimum essential coverage includes:
  • Preventive services, wellness services, and chronic disease treatment
  • Ambulatory patient services (outpatient care)
  • Emergency services (trips to the emergency room)
  • Hospitalization (treatment in the hospital for inpatient care)
  • Maternity and newborn care
  • Pediatric services
  • Mental health services and addiction treatment
  • Prescription drugs
  • Rehabilitative services and devices
  • Laboratory services
• Large employers must offer coverage to full-time workers or pay the penalty. Additionally, the ACA limited the waiting period that employers can impose on new employees for benefits to a maximum of 90 days.
• Under the current law, young adults can be added or stay on their parent’s plan until they turn 26 years old. Children can join or remain on their parent’s plan even if they are married. This closed the gap for young adults who are not offered health insurance at work or are still in school.

None of these consumer protections existed before the ACA. When diagnosed with cancer, understanding the important factors when choosing a health insurance plan can make all the difference for your future. With the cost of cancer treatment on the rise, planning ahead could greatly reduce the financial stress behind a serious diagnosis. If you’re looking for health coverage, visit HealthSherpa’s health insurance tool to explore the best options available for you.