- Covering the costs of cancer treatment
- Private health insurance options
- Types of private health plans available
- Other things to know about health insurance
- How to manage your health insurance
- Getting answers to insurance-related questions
- Keeping records of insurance and medical care costs
- When you have problems paying a medical bill
- Handling a claim denial
- Keeping employer-sponsored health insurance coverage
- COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986)
- The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- The Family and Medical Leave Act of 1993
- The Americans With Disabilities Act of 1990
- Government-funded health plans
- Who regulates insurance plans?
- Health insurance options for the uninsured
- Financial issues: Getting help with living expenses
- Getting money from life insurance policies
- Other sources of financial help
- Disability benefits
- To learn more
Private health insurance options
The new health care law known as the Affordable Care Act (ACA) is intended to make private health insurance more affordable for people with 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 Helps People With Cancer and Their Families. You can also call us anytime at 1-800-227-2345 for the most up-to-date information.
Group health plans
Many people get insurance coverage through a group plan offered by their employer. Under the new health care law employers with more than 50 full-time workers must offer health insurance or pay a penalty. 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 and receive financial assistance to help pay for it. Most people who receive health coverage through work will continue to do so under the health care law.
Group health plans cover a group of people, usually employees of the same company, and often their dependents. In general, employers must offer health coverage to full-time employees. Some employers pay part of employee health care premiums, which are the monthly payments for coverage.
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 new health care law 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 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 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
- Requires that most Americans buy health insurance or pay a penalty with their income taxes
Grandfathered health plans and cancellations
Individual health plans that do not meet the requirements of the new law, including those listed above, can continue to be sold only if they existed before the law was signed in March 2010. (These are called “grandfathered” plans.)
Unless a health plan stays essentially the same after March of 2010 and becomes grandfathered, it must adapt to the law or be discontinued. Because of this, many people across the country have received notice from insurers that their individual plan has been or will be canceled. State insurance commissioners now have the option to allow health plans slated to be cancelled at the end of 2013 to be sold for another year. In states where insurance commissioners approve, insurers will have 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 meets the law’s requirements. And whether or not insurers offer 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).
Not all individual plan cancelations have been due to the new law’s requirements. Insurance companies may decide for their own business reasons that they no longer want to sell a specific plan in a particular area of the country. Regardless of the reason, people facing the cancelation of their plan may have other options from their insurer, or they can look at plans sold in one of the new marketplaces.
Where to get private coverage: the health insurance marketplaces
You can buy your insurance coverage (online, by phone, mail or in person) through the new health insurance marketplaces. All plans sold in the marketplaces must meet the requirements of the new law that make sure plans cover certain benefits. Costs are held under control, and 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 or Medicare, 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 $45,960 per year and families of 4 with a combined income of up to $94,200 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 law 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 find your state marketplace by calling 1-800-318-2596.
Enrolling in a Marketplace Plan
Enrollment in the marketplaces began October 1, 2013. People who enrolled by Dec. 24 had coverage as of January 1, 2014. The first marketplace enrollment period ends March 31, 2014. Another open enrollment period will begin in November of 2014, though 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.
- 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.
When the state marketplaces opened in October 2013, some of them had technical problems that made it difficult if not impossible to use their websites and enroll in a plan. Many of the states running their own marketplaces fixed the problems within a few weeks, but the issues with the federally-run marketplace continued for much longer. Healthcare.gov is working much better now than it was then, but some users may still have problems. If you do, it might be best to choose one of the other options listed above, such as phone, mail, and in-person enrollment.
Last Medical Review: 12/31/2013
Last Revised: 12/31/2013