Health Insurance and Financial Assistance for the Cancer Patient

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Private health insurance options

The health care law known as the Affordable Care Act (ACA) is intended to make private health insurance more affordable, especially for people with serious diseases such as cancer. The law also ensures that most insurance plans cover the health care that cancer patients and survivors might need. This section looks at the law’s specific impact on different types of private health insurance.

For an overview of the new law, please read our brochure called The Health Care Law: How It Can Help People With Cancer and Their Families. You can also call us anytime at 1-800-227-2345 for the most up-to-date information and for answers to questions about health insurance.

Group health plans

Group health plans cover a group of people, usually employees of the same company, and often their dependents. Some employers pay part of employee health care premiums, which are the monthly payments required to continue coverage.

Many people get insurance coverage through a group plan offered by their employer. Under the new health care law, employers with 50 or more full-time workers must offer health insurance as of January 1, 2015 or pay a penalty. Employers with less than 50 full-time workers are not required to offer health insurance.

The law allows employees whose health insurance is too expensive (more than 9.5 percent of their income for the employee’s coverage) to buy a different plan through their state’s health insurance marketplace and receive financial assistance to help pay for it. Most people who now get their health coverage through work will likely continue to do so under the health care law.

Individual health plans

Individual health plans are sold by insurance companies directly to a person, not through an employer. Some individual plans also cover family members, or dependents. For many years, individual health plans could vary a lot by the types of health care services they covered, the amount of care they would pay for, how much they charged, and the types of people they covered. For example, insurance companies could look at your personal and family health history, and require physical exams or lab tests when deciding whether to insure you. Based on the results, they could decide not to offer you a health plan, or they could charge you higher monthly premiums than they did to younger, healthier people. They could require people who were sick or injured to pay more for their care or turn them down for coverage altogether. They also offered different levels of coverage, with most plans not covering the care needed by someone with a serious illness such as cancer.

The ACA makes major changes to individual health plans, many of which are designed to improve the coverage these plans offer and to make these plans more affordable for people with cancer or another serious illness. For instance, the law:

  • Requires health plans to cover people with a pre-existing condition such as cancer
  • Makes cancer screening tests, such as mammograms and colonoscopies, available at little or no cost to patients
  • Prohibits insurance plans from canceling coverage if patient gets sick
  • Requires that most individual health plans cover 10 categories of essential health benefits
  • Prohibits insurance plans from charging sick people – including those with cancer – more for coverage than healthy people
  • Prohibits annual and lifetime dollar limits on the amount of a patient’s care the plan will pay for
  • Requires insurers to provide current policyholders and people shopping for coverage with a short and simple summary of their coverage
  • Allows young adults to stay on their parents’ health insurance until age 26
  • Makes sure that patients who take part in clinical trials are covered for their other health needs
  • Helps individuals with low or moderate incomes buy health insurance
  • Requires that most Americans buy health insurance or pay a penalty with their income taxes

Grandfathered health plans, exceptions, and cancellations

Individual health plans that do not meet the requirements of the new law, including those listed above, can continue to be sold if they existed before the law was signed in March 2010 and have stayed essentially the same since then. (These are called “grandfathered” plans.)

Health plans that have made substantial changes to their coverage since March 2010, or have been created since then, must adapt to the law’s requirements, with some exceptions. One important exception applies to health plans that aren’t technically grandfathered but still do not meet the law’s requirements for coverage. These non-grandfathered plans, which apply to individual and small-group plans, may continue to be sold through Oct. 1, 2016.

Insurance companies can cancel a health plan for several reasons. However, plan cancelations have received more attention than usual since the health care law went into effect. People across the country have received notice from insurers that their individual plan has been or will be canceled. State insurance commissioners were given the option to allow health plans scheduled for cancelation at the end of 2013 to be sold for another year. In states where insurance commissioners approved, insurers were given the option to keep selling these plans to current policyholders. Keep in mind that these plans can still discriminate based on health status or history by charging more or denying coverage, because they are not required to comply with all of the patient protections included in the health care law. The plans cannot continue to offer coverage beyond the end of 2015.

It’s important to note that several insurers are offering people whose insurance was canceled a different plan that does meet the law’s requirements. Whether or not insurers offer policyholders this option, people whose individual plans are canceled can shop for coverage on the health insurance marketplace offered in their state, and may be able to receive financial help to pay for it (see below for more information on the marketplaces).

Where to get private coverage: the health insurance marketplaces

You can buy your insurance coverage (online, by phone, mail or in person) through health insurance marketplaces in each state. All plans sold in the marketplaces must meet the requirements of the ACA that make sure plans cover certain benefits. Patients receive straightforward information about the coverage offered. Individual health plans can still be sold outside the marketplaces, but the financial help that the law provides to help low- and middle-income people pay for coverage is only available with marketplace plans.

If you are under 65 and can’t get health coverage through your employer, you may be able to buy a health plan through your state’s health insurance marketplace. Low- and middle-income people and families can get financial help through the marketplace to help them afford a plan. People with health coverage through work whose health care premiums are too high compared to their income may also be able to buy coverage through a marketplace.

The health care law requires all health plans sold in a marketplace to cover essential health benefits, such as cancer screenings, treatment, and follow-up care. Each state’s marketplace puts the health plans into groups, or “tiers,” based on the level of coverage they offer and their cost to consumers. The highest tier is platinum, followed by gold, silver, and bronze. The platinum level is more costly up front, but tends to pay higher percentages and has lower deductibles. The bronze level is less expensive, but the out-of-pocket costs are higher in case of an illness.

After you give your information, the marketplace will tell you if you qualify for financial help to buy a plan. People who make up to $46,680 per year and families of 4 with a combined income of up to $95,400 a year should qualify for some help to buy a health plan through the marketplace. The marketplace will also tell you if you qualify for Medicaid, a government program that offers health coverage to low-income people.

The ACA gives states the choice to enroll more people in Medicaid coverage than ever before, but not all states have decided to do so. In those states, some very low-income people also won’t qualify for help paying for insurance in the marketplace. For details on whether you qualify and for how much, visit www.HealthCare.gov or CuidadoDeSalud.gov, or find your state marketplace by calling 1-800-318-2596.

Enrolling in a Marketplace Plan

The next open enrollment period is scheduled to start November 15, 2014 and end February 15, 2015. This is an opportunity for individuals to enroll in a new plan or choose a different plan. After February 15, 2015, people with a life-changing event such as the birth of a child can enroll in a marketplace plan at times outside of the open enrollment period. There are a few ways to enroll:

  • Visit www.HealthCare.gov, the federal government’s official marketplace website. Whether your state offers the federally run marketplace or is operating its own marketplace, you’ll be directed to the right website through www.HealthCare.gov. The Spanish version can be found at www.CuidadoDeSalud.gov.
  • Call the federal toll-free number at 1-800-318-2596 to enroll over the phone (TTY: 1-855-889-4325). Information about your state’s marketplace and the plans sold on it is offered 24 hours a day, 7 days a week in more than 150 languages.
  • Apply in person with the help of a trained counselor in your community. Find help in your area at localhelp.healthcare.gov.
  • Complete a paper application and mail it in. You can download the paper application form and instructions from www.HealthCare.gov or www.CuidadoDeSalud.gov.

Last Medical Review: 11/04/2014
Last Revised: 11/04/2014