The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010. Providing critical access to health care and insurance coverage to a record 35 million Americans in 2022, the ACA has evolved since its inception and its future remains unclear due to ongoing challenges at federal and state levels. Reading through the entire 906-page health care reform bill is possible, as it’s posted on the Internet. But to you save time, this article focuses on the provisions most important for those who are working or seeking work after a cancer diagnosis.
For simplicity, they’re grouped into four categories:
- Benefits and services
- Rules for insurance companies
- Routes to obtain coverage
- Staying up to date
Benefits and Services
Personal Responsibility. As of January 1, 2019, health insurance coverage is no longer mandatory at a federal level. However, some states do still require you to have coverage. Be sure to check with your state or tax preparer to find out if there is any fine for not having health insurance.
Help for Those With Pre-Existing Conditions. As of January 1, 2014, insurance companies can’t refuse to sell coverage or renew policies to persons with pre-existing conditions. Furthermore, women, as well as anyone with a pre-existing condition, can no longer be charged higher premiums for their health insurance. Additional details can be found at www.healthcare.gov/coverage/pre-existing-conditions.
Preventive care. Most new health plans sold on or after September 23, 2010, or those that renew after that date, must cover certain preventive health services, such as mammograms, flu shots, colonoscopies, and cholesterol checks, free of charge, without a co-pay, deductible or other cost sharing. Which other services are covered depends on the type of health care plan as well as factors such as your age. For a complete list of the covered services, visit www.healthcare.gov/what-are-my-preventive-care-benefits.
Appealing Decisions. All health insurance companies must now have an internal appeals process and all states must now have an external process for consumers to appeal health insurance companies’ decisions. For example, if your insurance company denies a claim on the basis that the procedure was experimental, you now have the right, in any state, to appeal that decision and show why it was not experimental. Those enrolled in a health plan must be provided with a notice about available internal and external appeals processes and be told of the availability of assistance to help complete the process. More information about this right can be found at www.healthcare.gov/marketplace-appeals/what-you-can-appeal
Rules for Insurance Companies
Restrictions and Bans on Coverage Limits. For health plans beginning on or after September 23, 2010, insurance companies cannot impose lifetime dollar limits on benefits that are deemed essential, such as hospital stays. A lifetime limit is defined as a cap on the total benefits your insurance plan will pay you, either for all benefits (e.g., a $1 million lifetime cap) or for certain benefits (e.g., a $200,000 cap on organ transplants).
Under the ACA, setting annual dollar limits on essential health benefits (such as for hospital stays) is banned altogether as of 2014. For more information visit www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits.
Routes to Obtain Coverage
Buying Insurance from the Marketplace. As of October 1, 2013, individuals can purchase health insurance from a state marketplace (otherwise known as an “exchange”). This is good news if you’re currently unemployed or if you are employed but your employer offers unaffordable or inadequate health insurance — or none at all. State health insurance marketplaces are open to individuals and small businesses (i.e., those with fewer than 50 employees); they offer a choice of competitive health plans that must meet certain standards with regard to benefits and cost, in addition to being affordable. Insurance companies must apply to sell their plans through each marketplace and provide coverage for essential health benefits.
The ACA also limits how much marketplace plans may require consumers to pay out of pocket for medical expenses in addition to their premiums. These caps will help keep out-of-pocket costs down and stem the tide of bankruptcies caused by medical bills. Marketplaces vary by state. States that run their own marketplace have websites you can visit directly to learn more about the options available. For more information about the Marketplace in your state, visit www.healthcare.gov.
Financial Assistance. When you apply for a health insurance plan in the market-place, you will be asked whether or not you are employed and whether your employer currently offers you coverage. You will also be asked to include some financial information. Based on all of this information, the marketplace can determine if you are eligible for any financial assistance options.
If you can’t afford the coverage offered by your employer, you may be able to take the funds your employer would have contributed toward your company plan and use them to obtain a plan from the exchange. People who buy plans in the marketplaces may also qualify for financial assistance to help them pay for their health insurance. This assistance is based on income level and family size. These subsidies will reduce the cost of healthcare expenses an individual or family must pay when they receive medical care — for example, by lowering the co-payment for visiting the doctor’s office.
The amount of tax credit you are eligible for depends on how much income you or your family earns. For an estimate of the amount of financial assistance you may be eligible for, use The Kaiser Family Foundation’s Subsidy Calculator.
Staying Up to Date
- To keep up with healthcare reform as it unfolds, check out www.healthcare.gov.
- For a year by year look at the new provisions, go here www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html.
- For the U.S. government's one page guide with tips for navigating the health insurance Marketplace relevant to where we are in the calendar year visit www.healthcare.gov/quick-guide/one-page-guide-to-the-marketplace.