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Health Care Reform: What Does It Mean for You?

The complex and controversial Affordable Care Act includes reforms that could benefit cancer patients and survivors. By Bara Vaida

The Affordable Care Act (ACA)—the health care reform law popularly called Obamacare—is expected to have a significant impact on cancer patients and survivors. The consumer protection changes in the law ensure that no one can be denied health insurance, regardless of medical history, and the law imposes new out-of-pocket limits that may reduce costs for many cancer patients and survivors.

Confused? Help Is Available
Resources are available to help you understand the health insurance process.
Under the law, U.S. residents must obtain health insurance to avoid a tax penalty. Cancer Today spoke with health care experts about what every cancer patient and survivor should keep in mind when considering insurance options. The important message is to look carefully at a plan’s benefits—a lot of variation exists in coverage and cost.

Besides guaranteed coverage, what are the benefits of the law?
The law applies to all health insurance plans, whether purchased by an individual, offered through an employer or provided by Medicare or Medicaid. Among the reforms are:

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An insurer cannot impose an annual or lifetime limit on how much it will pay for medical care.
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There are caps on out-of-pocket costs, like deductibles, copays and coinsurance.
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An insurer must pay for cancer screening tests, such as mammograms and colonoscopies, without charging a copay.
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Routine medical care associated with participation in clinical trials must be covered by insurance.
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A patient has the right to appeal to an insurer if denied payment for a service.
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Children are allowed to stay on their parents’ plans until they turn 26.

Of all these changes, the most beneficial to cancer patients may be the ban on lifetime coverage limits, because “people with cancer can rack up significant bills,” says George Weiner, an internist and director of the Holden Comprehensive Cancer Center at the University of Iowa in Iowa City.

What are the new insurance marketplaces, and why buy insurance there?
People who are uninsured, buy insurance on their own, can’t get insurance through an employer or find their employers’ insurance inadequate can go online to a marketplace to see and compare multiple insurance options and premiums. Purchasing insurance through the federal and state-run marketplaces (access to all the marketplaces can be found on healthcare.gov) is the only way to obtain a federal tax credit to help offset the cost of premiums or get help with out-of-pocket costs. If you purchase insurance outside the marketplaces, no tax credit is available. Those wishing to buy insurance through the marketplaces this year must do so during the enrollment period, which ends on March 31.

What do the plans cost?
Plans are broken into tier levels—bronze, silver, gold and platinum—based on their cost and benefits. Bronze plan premiums are the cheapest, but these plans also have high deductibles, copays and coinsurance. Platinum premiums are the most expensive, but the plans have lower out-of-pocket costs. The Leukemia & Lymphoma Society advises that bronze coverage, although inexpensive, “is insufficient for patients with high-cost medical needs” and suggests that cancer patients purchase silver or higher tier plans. The American Cancer Society (ACS) Cancer Action Network says a gold or platinum plan may be “the better choice” for cancer patients, as does the federal government. There is also a catastrophic tier, aimed at people under 30 and those who qualify for a hardship exemption, that features very high deductibles and is essentially a safety net for people who experience serious health events such as accidents or extended illness. The hardship exemption includes people whose health insurance has been canceled and who can’t afford to enroll in one of the four standard tiers.

How much will tax credits subsidize premium costs?
It depends on income and family size. For example, an individual with an annual income up to $45,960 and a family of eight with an income up to $158,520 may be eligible for a tax credit.

What benefits are available in marketplace insurance plans?
All of the plans sold must cover 10 essential benefits: ambulatory patient services (outpatient care), emergency services, hospital care, maternity and newborn care, mental health and substance use services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive services and chronic disease management, and pediatric care, according to the Department of Health and Human Services.

Are palliative care and hospice care covered?
It depends. Palliative care and hospice care are classified as a benefit under “ambulatory services,” but each state and insurance plan can decide how that benefit is met, according to Kirsten Sloan, the senior director of policy analysis and legislative support at the ACS’s Cancer Action Network.

Can people visit any doctor, specialist, hospital or treatment center, no matter where they are in the country?
It depends on the plan. Every plan in the marketplace must provide a list of doctors and hospitals in the plan. If a doctor or hospital you want is not on the list, the plan may not be the right one to buy. Many top cancer centers aren’t participating in all of the marketplace plans. Some plans may allow people to see doctors or visit hospitals outside the network, but they may charge patients more to do so, says Sloan. “This is why we encourage people not to just look at premiums but to also look at copays and deductibles” when picking a plan.
 

01/24/2014
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