The Affordable Care Act (ACA) requires that just about everyone in the United States will have to have health insurance by Jan. 1, 2014, or pay a penalty. Most types of health insurance will count towards this requirement including employer sponsored insurance, Medicare, Medicaid, veterans’ benefits, and individually purchased plans.
To help us all understand what the ACA means for women diagnosed with breast cancer, Breastcancer.org turned to Monica Fawzy Bryant, cancer rights attorney and chief operating officer of Triage Cancer, a national nonprofit organization offering education and resources on cancer survivorship issues.
“The language of the law may be confusing and the glitches on the website problematic, but overall, the ACA is positive for women with breast cancer,” Bryant said. “Looking at the big picture, it gives people new ways to purchase insurance and makes insurance as affordable as possible.”
Here are some of the highlights of the ACA that directly relate to breast cancer treatment and detection. Most of the provisions will begin in 2014, though some started earlier.
- You can’t be denied coverage if you’ve been diagnosed with breast cancer. In the past, many insurance plans could deny coverage to women who’d been diagnosed with breast cancer because it was considered a pre-existing condition. Starting in 2014, this practice is forbidden.
- You can’t be kicked off your insurance plan for being diagnosed. Some women who were diagnosed with breast cancer found their coverage suddenly ended when their insurer found out about the diagnosis. This practice has been forbidden since September 23, 2010.
- You won’t have to worry about an annual or lifetime limit on coverage. Many cancer patients found themselves unable to pay for care after they hit a yearly or lifetime limit on the amount an insurer would pay for treatment. Beginning in 2014, the ACA eliminates limits on essential health benefits, ensuring that your care will continue as long as you need it. (Learn more about essential health benefits.)
- You can’t be charged more for coverage because you’re sick or because you’re a woman. According to Bryant, many insurers traditionally charged women more than men for coverage. The roots of this difference in cost have been lost over time. The ACA now says that insurance companies can look at only four factors when setting rates:
- your age
- where you live
- is the plan for an individual or a family?
- do you use tobacco?
States can limit these factors even more. California has said that tobacco use can’t be considered in rate setting. New York has eliminated everything except for where someone lives — insurance companies can consider only that one factor when setting rates.
- You can get breast cancer preventive care at no cost. The ACA requires insurers to cover preventive mammograms every 1 or 2 years starting at age 40. Insurers also must cover BRCA1 and BRCA2 genetic testing and counseling for women with a family history of breast and/or ovarian cancer. No cost means there is no out-of-pocket copay cost for you. It’s important to know that if you’ve been diagnosed with breast cancer, mammograms are rarely considered preventive, which means you may be liable for a copay or deductible amount.
- If you’re in a clinical trial, your insurance will cover your routine care. In the past, some insurance companies would refuse to cover any care for women who were part of a clinical trial. This meant that the person or the clinical trial had to pick up these costs. Starting in 2014, the ACA says that insurance companies must pay for routine care for people who are in clinical trials. “In some cases, this will depend on the situation,” Bryant explained. “Say you’ve been diagnosed with breast cancer and the standard of care is for you to have mammograms every 6 months. That would be considered routine care. But say you’re in a clinical trial that calls for you to have a mammogram once a month. Your insurance would be required to pay for two of the 12 mammograms you get each year and the trial would pay for the other 10. “My advice to patients is to ask questions,” she added. “Don’t just pay if your insurance says the service isn’t covered because you’re in a clinical trial. Most trials have a person who serves as a patient advocate. Start with that person and figure out what’s covered and what isn’t before you pay anything.”
It’s important to know that the provisions mentioned above have one big exception: “grandfathered” insurance plans. These are plans that existed as of March 23, 2010 and haven’t made significant changes, such as significantly reducing benefits or increasing costs.
“Grandfathered plans don’t have to comply with all of the ACA’s provisions,” Bryant explained. “If someone has insurance through a plan overseen by a larger employer, it may be a grandfathered plan.”
The American Society of Clinical Oncology estimates that by 2014, 36% to 66% of patients covered by large employers will remain on grandfathered plans and 20% to 51% of patients covered by small employers will remain grandfathered. The number is likely to decrease over time as plans change benefits and costs. If you’re not sure whether your plan is grandfathered, Bryant advises talking to your plan administrator or HR person.
Plans purchased after March 23, 2010, including those sold in the new insurance marketplaces, must follow all the ACA provisions.
These health insurance marketplaces (covered in the Sept. 30, 2013 blog) are another plus for women diagnosed with breast cancer, in Bryant’s opinion. The marketplaces are aimed at the roughly 10% to 15% of the U.S. population who don’t have health insurance or people who buy their plans individually. The marketplaces also are open to people who have coverage through their employer, but that coverage is considered unaffordable or inadequate.
“People between 138% and 400% of the federal poverty level — about $94,000 per year for a family of four — may be eligible for financial assistance to purchase plans in the insurance marketplaces,” Bryant said. “Depending on your income level and family size, people may get tax credits to reduce premiums and subsidies that reduce copays. These tax credits and subsidies apply to everyone — they’re not dependent on which state you live in.”
The Kaiser Family Foundation website features a calculator to help you figure out your marketplace insurance costs and any tax credits and subsidies for which you might be eligible.
Let us know if you have specific questions about the ACA and breast cancer, and we’ll try to get the answers!