How Health Care Reform Affects Your Cancer Care

If you have cancer, the Affordable Care Act gives you protection against losing insurance coverage and protects the health care benefits you have.

Cancer and Insurance Coverage

Health plans* have to help pay for your cancer treatment. You have rights as a cancer patient under the Affordable Care Act:

  • Your insurance cannot be canceled because you have cancer.
  • You cannot be denied insurance if you have cancer.
  • Children with cancer cannot be turned down for coverage.
  • If you qualify and want to take part in a clinical trial, your health plan must help pay for routine costs associated with approved clinical trials. A trial may help you get new cancer treatments.

Limits on How Much You Have to Pay for Cancer Treatment

The Affordable Care Act has rules about the most you have to pay out-of-pocket for the medical care you get from your doctors and the hospitals that participate in your plan. These protections are available even if you have cancer:

There is no dollar limit on how much an insurance company spends on covered expenses for your health care. Annual and lifetime limits have gone away.

If you are sick, you cannot be charged more for health insurance.

Your out-of-pocket costs will be limited. There's a maximum amount, or cap, on how much you'll have to spend on copays, coinsurance, and deductibles.

If you enroll in a health plan through your state's Marketplace or have a health plan from your employer that covers medical and pharmacy costs for 2018, these are your spending caps or maximums:

  • If you are single, your out-of-pocket costs for in-network care are capped at $7,350 per year.
  • For a family, the cap is $14,700 for one year.

You might be able to get financial help to pay for some costs if you're buying insurance through your state's Marketplace. Both tax credits and cost-sharing subsidies are available to people with qualifying incomes. Check on healthcare.gov to find out.

You might qualify for Medicaid, even if you haven’t qualified in the past. Some states have expanded Medicaid to cover more people. Check with your state’s Marketplace to find out if your state is one of those.

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Mental Health Support During Cancer Treatment

Many people have depression and anxiety during cancer treatment. You can get depression screening at no extra cost. Health plans sold on state Marketplaces, through the individual market, and through small employers must cover mental health services. While employers with more than 50 employees don’t have to cover mental health services, most do.

In addition, mental health services must be provided under the same terms and conditions as other health care services. Health plans can no longer provide more limited mental health benefits than they do for other health care benefits. How much you pay for your care will depend on the plan you enroll in.

You can also get these services through Medicare and Medicaid.

Savings on Cancer Drug Costs for Seniors

If you are on Medicare Part D, the Affordable Care Act is eliminating the so-called “donut hole.” That’s a gap in your prescription drug coverage. Prior to the Affordable Care Act, that made you pay the full cost of meds once you reached the annual drug-spending limit.

If you're in the donut hole in 2018, you'll pay 35% of the cost of brand-name drugs (25% in 2019) and 44% of the cost of generic drugs that are covered under Medicare Part D (37% in 2019). By 2020, Medicare's donut hole will close and you’ll pay just 25% of the cost of both brand-name and generic drugs.

Essential Health Benefits

If you buy health insurance through your state's Marketplace, on the individual market, or get them from an employer with fewer than 50 employees, your plan must cover certain essential health benefits. You may need some of these services as a cancer patient, including such services as:

  • Chronic disease care
  • Emergency care
  • Hospital care
  • Lab services
  • Mental health services
  • Outpatient treatment
  • Prescription drug coverage
  • Rehabilitation services

Be aware that each state determines exactly what must be covered under these categories. Individual health plans may add to those minimum requirements. It's important to read the plan's summary of benefits to see what your costs will be before you enroll.

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* Grandfathered health plans, those that existed before the Affordable Care Act was passed and have not significantly changed, are not required to offer some of these protections, such as bans on pre-existing conditions or annual limits on benefits. Check with your insurance company or HR department to find out if you’re in a grandfathered plan. In addition, short-term health plans do not have to offer these benefits or protections. Short-term health policies are those in effect for less than 12 months, although they can be renewed for up to 3 years.

 

 

WebMD Medical Reference Reviewed by Sarah Goodell on September 18, 2018

Sources

SOURCES:

American Cancer Society: "The Health Care Law: How It Can Help People With Cancer and Their Families;" "Six Ways the Affordable Care Act is Helping Cancer patients;" "Health Insurance and Financial Assistance for the Cancer Patient;" and "Essential Health Benefits."

Fight Colorectal Cancer: "ACA Mandates Insurance Coverage for Clinical Trials."

U.S. Preventive Services Task Force: "USPSTF A and B Recommendations."

HealthCare.gov: "Will I Qualify for Lower Out-of-Pocket Costs?" "Income Levels that Qualify for Lower Health Coverage Costs;" "How to Save on Out-of-Pocket Health Care Costs;" and "How to Save on Monthly Insurance Premiums."

White House: "Historic Consumer Protections Take Effect, On Time."

Community Catalyst & Georgetown University Health Policy Institute: "Federal Subsidies: Helping People Afford Health Care."

Medicare.gov: "Closing the Coverage Gap – Medicare Prescription Drugs Are Becoming More Affordable" and  “More Savings in the Drug Coverage Gap Coming Through 2020.”

CMS.gov. “Final HHS Notice of Benefit and Payment Parameters for 2017.”

Kaiser Family Foundation: "Visualizing Health Policy: Medicaid Expansion Under the Affordable Care Act."

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