November 2014 Ask the Expert: The Affordable Care Act and You
The Affordable Care Act, signed into law on March 23, 2010, changed many aspects of the US healthcare system. As a person living with breast cancer, many of these changes affect you. There may even be protections and coverage requirements you haven’t heard about.
You may find yourself asking whether certain treatments or procedures are covered by your insurance, what to expect from your insurance company for reconstruction or prescriptions, or how to handle genetic testing if you come from a family with a history of disease.
Understanding health insurance can be overwhelming, and navigating policies when federal and state laws change may make it even more confusing. During the month of November, Living Beyond Breast Cancer expert and CEO of Triage Cancer, Joanna L. Fawzy Morales, Esq, answered your questions about the Affordable Care Act and how it impacts your care as a person living with breast cancer.
Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical or legal advice.
Ms. Morales: There is no requirement that employers offer health insurance to their employees. The Affordable Care Act does require employers with more than 50 employees to pay a penalty if they do not offer health insurance coverage to their employees (a.k.a. the employer mandate, which has not yet gone into effect). However, it does not require employers to cover the full cost of the monthly premiums.
Many people are offered employer-sponsored coverage but have to pay the full amount of the monthly premium or just part of the premium. Employers are allowed to require employees to pay more or less of the monthly premium each year, if those employees would like to have the coverage from the employer. Even if the employer does not offer annual salary raises, the employer could still require the employee to pay 100 percent (or less) of the health insurance premium, if the employee would like to have the employer’s health insurance plan. If you are a member of a union, you may be covered by a union contract that has additional rules, so talk with your union representative.
Ms. Morales: The Affordable Care Act, ACA, does not specifically state that supplements or organic products be covered under a health insurance plan. Each health insurance company treats these items differently; however, organic food is not typically covered by health insurance plans.
The ACA only requires that individual and small group health insurance plans cover 10 categories of essential health benefits: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Each state defined coverage for these categories of care in more detail.
The ACA also requires all non-grandfathered health insurance plans to provide free preventive care. Click here to see the complete list of preventive services that are not only covered by health insurance plans, but have no out-of-pocket cost to you.
It is very important for everyone to check to see if their providers are covered by plans that they are shopping for as well as to see if their prescription drugs are covered.
Ms. Morales: The United States Preventive Services Task Force (USPSTF) issues guidelines for preventive services and provides them with grades. Any preventive service with an ‘A’ or ‘B’ grade is on the list of no-cost preventive services under the ACA, except for mammography.
Although mammography for women between the ages of 40 and 50 does not have an ‘A’ or ‘B’ grade, it is still covered as a free preventive service by the ACA. The guideline for mammography has no upper age limit: “breast cancer mammography screenings every 1 to 2 years for women over 40.” The ACA does not limit coverage of mammograms at all. Click here for an in-depth review of this issue.
Ms. Morales: The ACA does require individual and small group health insurance plans to cover breast cancer chemoprevention counseling for women with a higher risk, as a preventive service. In addition, on September 24, 2013, the USPSTF issued a new recommendation for the risk reduction of breast cancer. The recommendation now says: “that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.”
Therefore, for plan years beginning on or after September 24, 2014, non-grandfathered individual and group health insurance plans are required to cover such medications with no out-of-pocket cost to you.
Ms. Morales: Generally, employers are allowed to change health insurance plans at any time without the permission of employees and without prior notice. Employers must comply with ERISA and any relevant union rules if applicable. Employers are not required to provide health insurance coverage to employees (see above).
Ms. Morales: The best place to start when searching for health insurance options that might be available to someone, is HealthCare.gov. You only need to answer a few simple questions about where you live, your age, and your income level, and you can find private health insurance plans that are available to you. By providing your income level, you can also find out if you qualify for Medicaid in your state, or if you qualify for financial assistance to lower the cost of your monthly health insurance premiums. Click here for more information. Also, if you know someone who may need more one-on-one assistance in figuring out their health insurance options and how to apply, they can visit https://localhelp.healthcare.gov and enter in their zip code to find trained and certified “assisters” in their area who can help.
Ms. Morales: Medicare does have some guidelines with regard to coverage for PET/CT scans for a cancer diagnosis, but the guidelines are different based on the timing of the use of PET/CT scans and for the type of cancer diagnosis. For example, click here for more information. However, Medicare typically allows for coverage when a treatment or procedure is determined to be medical necessary. Double check your coverage by contacting your State Health Insurance Assistance Program, by entering in your zip code here. In order to determine if a particular Medigap plan available in your area covers a particular procedure, you would need to contact that plan directly. To identify Medigap plans in your area, visit http://www.medicare.gov/find-a-plan/questions/medigap-home.aspx. If Medicare has denied the fifth PET/CT scan, then you can appeal that decision.