Rights and Protections Under the Law

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The health law includes protections for consumers that:

  • Improve the quality of health insurance.
  • Increase access to health insurance.
  • Hold insurance companies responsible for the s they collect.

How does the law help protect individuals and families?

The health reform protects you in many ways, including:

  • Insurance companies must cover you even if you have a pre-existing health condition.
  • Insurance companies cannot cancel your health insurance policy because you get sick.
  • Insurance companies cannot charge more money because of your gender, health status, or job.
  • Health insurance plans must cover a list of , including:
    • Emergency services.
    • Care for pregnant women, new moms, and babies.
    • Prescription drugs.
    • Preventive services like health screenings.
  • Insurance companies cannot set limits on how much they will pay for covered essential health benefits in a year or over your lifetime. This means you will not run out of coverage if you develop a serious health problem.
    • It is important to know that the ACA bans annual limits – a dollar limit on what an insurer will spend for your covered benefits. The exceptions are on health care services that are not considered essential health benefits and grandfathered individual health insurance policies. 
    • Annual and lifetime limits can be applied to nonessential . For example, your health plan can limit how much it will cover for dental care each year (if anything) or over your lifetime. This is because dental care for adults is not considered an essential health benefit.
  • Health insurance plans must cover recommended preventive health services without . This means if you go to the doctor for an annual checkup, you will not owe a .
  • Young adults can be covered under their parents’ health insurance until they turn 26 years old.
  • Health insurance companies must spend at least 80% of your premiums on health services and activities that improve the quality of care.
    • The insurance company will owe money back to you or your employer if they do not meet this standard.
  • If a health insurance company raises premiums 10% or more, the federal government will review the increases to make sure they are fair.
  • There is a review process if you the insurance company’s denial to pay for your health care services. You will get a full and fair review of why your claim was denied. You will also have the option to have an independent review of your appeal.

Affordable and minimum value coverage

Employers who offer insurance may be subject to penalties if the coverage they offer is not considered affordable or does not provide a minimum level of coverage. To be considered affordable coverage, a worker’s share of premiums should be less than 9.5% of their pay. For example, if a worker is paid $35,000 a year, his or her share of premiums for individual coverage should be less than $3,325 for the year.

For coverage to meet the minimum value requirement, it should have an actuarial value of 60%. For example, if a covered health service costs $100, the health plan would pay $60 and the worker would be responsible for paying $40.

Premium

A premium is the cost of your health insurance. Premiums may be paid by you, your employer, or both. It is usually paid monthly or every three months. Or, it can be paid all at once for the whole year.

Essential Health Benefits

The 10 kinds of health care services most insurance plans must now cover, including care to help prevent disease, care for children, emergency care, prescription drugs, and more. Learn more about essential benefits here.

Benefits

Benefits are the health care services and items covered under a health insurance plan. Benefits vary based on your specific health insurance plan. Under the health law, essential health benefits are a set of benefits new health plans sold to individuals and families must cover.

Cost sharing

Cost sharing is what you pay for health services out of your own pocket. Most health insurance plans have some type of cost sharing. Deductibles, coinsurance and co-pays are all types of cost sharing. Health insurance premiums are generally not considered part of cost sharing.

Co-payment/Co-pay

A fixed amount you may pay at the time you receive a health care service – for example, you may pay $15 when you go for a doctor visit.

Appeal

An appeal is when you ask your health insurance company to review and change a decision it has already made. For example, you may ask your insurance company to pay for a treatment it already said it will not cover.