The Affordable Care Act: The Basics Cancer Patients Need to Know


Christina Bach, MSW, LCSW, OSW-C
Christina Bach, MSW, LCSW, OSW-C

An ounce of prevention is worth a pound of cure

We’ve already seen SOME of the impact of The Affordable Care Act (ACA) on preventative care measures.  Some of these preventative care measure  include no cost / no co-pay routine screenings (depending on your age) such as, blood pressure and diabetes screenings, cancer screenings including mammography and colonoscopy, smoking cessation and nutrition counseling, regular well-baby and well child visits from birth to age 21, and vaccinations including measles, polio and meningitis.  And, if you are over 65, and a Medicare beneficiary, Medicare will pay for part or all of your influenza (flu), pneumococcal (pneumonia) and hepatitis B vaccines.

All of this change attempts to shift focus from crisis-oriented acute care to preventive measures that will help decrease incidences of cancer, uncontrolled  chronic diseases like hypertension and diabetes, and diseases that are totally avoidable with vaccination.  Never before has the U.S. healthcare system placed this much emphasis on the prevention of disease.

See you later Pre-Existing Condition Clauses!

Perhaps the biggest impact on cancer patients beginning in 2014 is the end of pre-existing condition exclusions.  Starting January 1, 2014, an insurance company can no longer deny or limit coverage to adults based on a pre-existing condition.  Pre-existing condition exclusions for children have been prohibited since 2010 under the ACA. Also, insurers can not charge more for coverage to those with a pre-existing condition.

Kick that annual/lifetime coverage cap to the curb

Under the ACA, lifetime caps on health insurance coverage for MOST benefits are prohibited for any health plan or insurance policy issued or renewed on or after September 23, 2010.  This means that an individual can no longer max out of their insurance coverage for LIFE after a catastrophic illness.

Annual caps for coverage are also being phased out; and as of January 1, 2014 no annual caps can be imposed on most covered benefits.

Get your donut holes at Dunkin Donuts, not the pharmacy

The ACA also includes a mandate to slowly close the Medicare donut hole, increasing the coverage liability of manufactures/pharmaceutical companies and the government while systematically decreasing the individual’s out of pocket expenses.  This slow closing of the donut hole will occur over the next six years with completion in 2020.  Over the course of the next six years, recipients with Part D coverage will receive discounts on medications while they are in the coverage gap/”donut hole” period.    For example, in 2014, the discount for brand name medications while in the donut hole will be 52.5 % and the discount for generic drugs will be 28%.  This can represent significant savings for high dollar cost cancer medications.    A great resource to help you understand the interplay between Medicare and the ACA can be found here,

The potential expansion of Medicaid

Another important mandate of the ACA was the option for states to expand Medicaid eligibility to those making less than 133% of the federal poverty level (in 2013 = $14856 for an individual).  The expansion of Medicaid would be almost entirely funded by the Federal government.   Sadly, many states have opted out of this provision and patients who are still fairly low income will be forced to seek out coverage through exchanges.  So far, only 21 states have elected to expand Medicaid while 26 states are unclear or leaning against expansion.  Learn more about your state’s status.

The Healthcare Marketplace

Healthcare exchanges also known as the healthcare marketplace opened on October 1, 2013 through the healthcare.gov website.  For the first time, uninsured Americans now have the option to purchase medical insurance coverage.  Also, depending on household income, individuals may receive a subsidy to offset the cost of having medical insurance.

For example, insurance coverage for a family of four in Pennsylvania with a combined income of $35000 would cost $7517.  However, due to income the family would receive a subsidy of $6144 towards the cost of medical insurance, leaving the premium expense for the family of $1373 per year.  Calculate your own potential expenses.

There are five types of plans being offered:

  • Bronze:
  • Silver
  • Gold
  • Platinum
  • Catastrophic* only for individuals under 30; covers only catastrophic illness

Each plan differs in cost based on level of coverage elected:  Bronze (60/40) , Silver (70/30), Gold (80/20), and Platinum (90/10).  There are also maximum out of pocket (MOOP) expenses ($6350 for an individual and $12700 for a family).  After the MOOP is reached, the plan covers healthcare costs at 100%.  The price of the plans is based the type of coverage elected (i.e. a bronze plan is less expensive than a platinum plan) as well as the individuals age, geographic location of residence and tobacco use.  To reiterate, insurance prices or coverage can no longer be tied to pre-existing medical conditions.

The Individual Mandate

Perhaps the most controversial part of the law, the individual mandate requires most individuals to have health insurance and imposes penalties on those who chose to remain uninsured.  The penalty for not having health insurance is collected annually as a fine through annual IRS tax filings.  In 2014, the penalty for NOT having health insurance is $95.  This penalty will increase incrementally to $695 or 1 % of individual/family income by 2016.  Individuals who are NOT required to purchase health insurance through the healthcare marketplace include those with:

  • Religious objections
  • Financial hardship
  • Taxpayers with income <$9750 (single under 65-filing threshold)
  • Members of Indian tribes
  • Member of health care sharing ministry
  • Incarcerated individuals
  • Americans living abroad for > 1 year

One argument against the individual mandate is that the penalty for not having insurance is much let expensive then purchasing health insurance through the marketplace.   A word of caution though, taking a chance with NOT having insurance is exactly that, a chance.  Should the individual have an accident or illness and have no coverage, he/she will be responsible for medical costs incurred.  It is unclear how the ACA will impact the acquisition of care for the uninsured beyond emergency care&emdash;stay tuned.

Where can I get more information?

Interested in a little LIGHT reading?  You can read the ENTIRE affordable care act law, as well as get other information about the programs included in the ACA.

great infographic explaining the potential Medicaid expansion.

The ACA also mandates the streamlining and simplification of ALL applications for medical insurance coverage.  The proposed short form application for health insurance through the exchange program can be viewed online.

To explore the Healthcare Marketplace and your options to purchase insurance, go to www.Healthcare.gov

On October 25, 2013, Oncolink will be hosting an online interactive education session about the Affordable Care Act.  Join us online and on the phone!

Learn more or participate in the event

This article was originally written for and published in the Cutaneous Lymphoma Foundation’s Forum newsletter. The Cutaneous Lymphoma Foundation is an independent, non-profit patient advocacy organization dedicated to supporting every person affected by cutaneous lymphoma. Visit our website at www.clfoundation.org.