The Affordable Care Act (ACA) requires health insurance plans sold through www.healthcare.gov and its state-based marketplaces to comply with a number of requirements. Many of these–including the ones described below–are meant to ensure that patients have access to meaningful health insurance coverage. It’s important to be aware that some health plans, available today through non-governmental sites, may not include these patient protections.
Pre-existing conditions: Health insurers selling coverage through the marketplace cannot refuse to enroll children or adults due to pre-existing medical conditions like cancer. Health insurers must also cover treatment for any pre-existing conditions starting on Day 1 of your new health insurance plan.
Rescissions (Plan cancellations): In the past, health insurers could cancel coverage due to an error or technical mistake in a person’s health insurance application. The ACA made this practice illegal. Now, insurers may cancel or “rescind” your plan only if you commit fraud, intentionally lied on your application, or stop paying your premiums.
Premium rating: Health insurers cannot change your premiums based on a pre-existing medical condition, health history, or gender. The ACA permits insurers to adjust premiums based only on age, geographic location, and (in some states) tobacco use.
Annual or lifetime limits: Health insurers cannot set annual or lifetime limits (sometimes known as “caps”) on how much they will pay for the benefits that are covered by your plan. You may still be responsible for paying a portion of the cost of your care.
Purchasing coverage through the marketplace
The ACA created the health insurance marketplace to facilitate access to coverage for individuals and certain small businesses. Every plan sold through the marketplace must meet a number of requirements. This includes covering a minimum set of benefits and following the federal government’s limit for costs that the plan may require the consumer to cover.
Depending on your household income, you may be eligible for an “advance premium tax credit,” or “APTC,” to help lower the cost of your premiums. APTC amounts are much higher this year than in previous years and there is no longer a hard income cutoff. If your household income meets certain other standards, you may be able to purchase a “Silver” plan that has lower out-of-pocket costs in addition to lower premiums.
It is important to keep in mind that only plans sold through www.healthcare.gov and the authorized marketplace for your state are authorized to offer these potential cost savings. These plans are also guaranteed to include the patient protections described above. There are many other kinds of products for sale that might be called “health insurance” but which might not include the patient protections that are critical to cancer care. This can include, for example, “short-term limited-duration” plans, Farm Bureau plans, healthcare sharing ministries, and association health plans. When in doubt, or when a deal seems too good to be true, check www.healthcare.gov or call your state’s marketplace or department of insurance to ask for assistance.
The marketplace can also help you determine if you or members of your family may be eligible for Medicaid. You can enroll in Medicaid anytime throughout the year, if you're eligible.
Comparing plans
Open enrollment runs from November 1 to January 15 federally and in most states, though some states end open enrollment December 15. It is important to comparison-shop for your health insurance coverage every year. Even if you like the plan you have, it might be worthwhile assessing whether one of the options available this year is better suited to your current needs.
While you’re shopping for coverage, it is important to remember that premiums are just one piece of the total cost of any health insurance plan. Typically, plans will also require you to pay “cost-sharing.” This means having to pay out of your own pocket to cover a portion of the total cost of your care. Cost sharing might include copays, deductibles, and coinsurance. Cost-sharing amounts can vary greatly between plans, which is why it is important to pay close attention to those details when shopping for coverage.
Some plans can have very high deductibles. A deductible is the amount of money you must pay out-of-pocket before your plan begins paying for your care. Depending on the plan, this could mean you have to pay the full cost of certain office visits, specialty services, or prescription drugs until you’ve met your deductible.
Sometimes a plan will use “coinsurance.” Coinsurance means that instead of paying a flat dollar amount (like a copay), you will pay a percentage of the total cost of a drug or service, and the plan will pay the rest. For some cancer medications, this can translate to hundreds or even thousands of dollars for one month’s supply of that drug.
When it comes to prescription drugs, it is equally important to compare plans carefully. Every plan has a list of drugs that it will cover, called a “formulary.” Make sure that your drugs are listed on the formulary for the plan you are considering and be sure to review the cost-sharing assigned to those drugs.
The ACA sets limits on the total amount you will have to pay in out-of-pocket costs over the year. Find the current costs at healthcare.gov. Some plans will have lower limits, but no plan can have higher out-of-pocket costs than these amounts. It is important to remember that this limit does not include certain costs, such as premiums, most out-of-network medical care, and services and medications that are not already covered or approved by your plan.
The worksheets below may help when you are thinking about the many financial concerns that come up after you have received a blood cancer diagnosis.
Use these worksheets to keep track of questions to ask your healthcare and financial team members. Staying organized helps decrease many financial stressors and allows you to focus on feeling better.
Insurance Costs Checklist and Budget Form
Insurance Appeal Tracking Form
Financial Assistance Record
ACA frequently asked questions (FAQs)
The health insurance marketplace–sometimes referred to as the health insurance exchange – is where consumers can purchase health insurance plans that comply with the patient protections in the ACA.
The marketplace is an important resource for individuals and families who don’t already have high quality coverage through Medicaid, Medicare, or an employer. Many of those individuals and families–including some with employer-sponsored coverage–will qualify for financial assistance from the federal government to help pay for coverage purchased through the marketplace. That assistance can dramatically reduce monthly premiums and, for certain consumers, their out-of-pocket expenses as well. To find out more, visit www.healthcare.gov.
The marketplace can also help you decide if you or members of your family may be eligible for Medicaid. You can enroll in Medicaid anytime through the year, if you're eligible.
The best place to start is www.healthcare.gov. This website is hosted by the federal government and serves as the entry point for consumers who want to purchase health insurance coverage through the marketplace. If you live in a state with its own marketplace, www.healthcare.gov will transfer you to the website for that state’s marketplace.
The marketplace sites will calculate, based on your income, whether you qualify for financial assistance to help pay for your coverage or whether you’re eligible for coverage through Medicaid.
Open enrollment is an annual period during which consumers select their health insurance plan for the following calendar year. Check healthcare.gov.
No. According to the ACA, you cannot be denied coverage or charged a higher premium for your coverage due to any pre-existing condition, including cancer. However, this protection is only guaranteed in plans that adhere to the ACA, like the plans sold through the marketplace.
Remember there are many other kinds of products for sale that might be called “health insurance” but which don’t adhere to the patient protections that are in the ACA. These products can include, for example, “short-term, limited-duration” plans.
This will vary depending on where you live. In some states or regions, there may be multiple health insurers offering a variety of plans. In other places, there may only be one or two insurers offering plans.
The choices will be broken down into four “metal tiers:” bronze, silver, gold, and platinum. Bronze plans tend to offer less coverage in exchange for a lower premium, while platinum plans typically provide robust coverage but come with a higher premium. Platinum plans are not available in all areas.
Typically, a health insurance plan will require you to pay “cost sharing” – that is, a portion of the total cost of your care. Cost sharing might include copays, deductibles, and coinsurance.
A deductible is the amount of money that a consumer must pay out-of-pocket before the plan begins paying for any care. Depending on the plan, this could mean you have to pay the full cost of certain office visits, specialty services, or prescription drugs until you’ve met your deductible. For instance, if your plan has a $1,000 deductible, you are expected to spend $1,000 out of your own pocket for covered benefits and services before your plan begins to make payments on your behalf. Deductibles have grown significantly in recent years, and consumers should make sure they understand the deductible for each plan they are considering. Note that some plans include more than one deductible.
Copays are flat dollar amounts that a consumer might be required to pay to see a doctor, for example, or to purchase a prescription medication. Coinsurances are different than copays because they require the consumer to pay a percentage of the total cost associated with a doctor visit, for instance, or a prescription drug. Due to regional variations in cost and the high prices of many services and medical products, coinsurances can be difficult to estimate in advance and often mean very high out-of-pocket costs.
Deductibles and coinsurance are important for blood cancer patients to consider when shopping for health insurance coverage, as these two factors will enable patients to better understand the total costs they will be expected to pay in addition to a plan's premium.
The open enrollment period is the only time during the year when you can switch coverage. If you decide during the year that your coverage isn't adequate, you will not have an opportunity to switch to a different plan until the next open enrollment period. The only exception to that is if you experience certain life-changing events during the course of the year, such as marriage, divorce, pregnancy, changes in income, the loss of employer-provided coverage, or a qualified hardship.
You will need to review the documents provided for the health insurance plans you are considering. Look for each plan’s formulary–—the list of drugs covered by the plan–—and search for the name of each medication you take. Cost sharing for each medicine should be listed on the formulary as well.
If you provide information during the enrollment process about your household income, the marketplace website automatically determines whether you qualify for financial assistance. This may include a tax credit to help pay your premiums or eligibility for a plan that has reduced cost-sharing requirements.
Yes, you may still be eligible to receive this form of assistance from us, provided you still qualify under the conditions of the Blood Cancer United Copay Assistance Program.
If you have questions or want more information, please contact an Blood Cancer United Information Specialist.
We want your feedback!
We are committed to removing access barriers for blood cancer patients. If you experience high treatment costs, poor access to your provider or hospital, or a delay in getting timely care, please share your story with us at [email protected]. If you have a positive experience, we would like to hear that too. Making your voice heard can really make a difference.
Blood Cancer United resources
Find free, specialized guidance and information for every type of blood cancer, request financial support, find emotional support, and connect with other members of the blood cancer community.