The Affordable Care Act (ACA) took effect on September 23, 2010. It includes certain rights and protections for consumers. These rights and protections help make coverage of health care services fairer and easier to understand.
Insurance plans on the Health Insurance Marketplace must provide these rights, just like most other types of health insurance.
Certain rights may not be covered by some health plans, such as grandfathered health plans. Such insurance consists of an individual health insurance policy purchased on or before March 23, 2010.
Always check your health plan benefits to make sure what type of coverage you have.
Information
RIGHTS AND PROTECTIONS
Here are some ways health care laws protect consumers.
You must be covered, even if you have a pre-existing condition.
- No health insurance plan can turn you down, charge you more, or refuse to pay for essential health benefits for any condition you already had before your coverage began.
- Once you’re enrolled, the plan can’t deny you coverage or raise rates based solely on your health.
- Medicaid and the Children’s Health Insurance Program (CHIP) also cannot deny you coverage or charge you more because of a pre-existing condition.
You have the right to free preventive care.
- Health plans must cover certain types of care for adults and children without charging you a copay or coinsurance.
- Preventive care includes blood pressure screenings, colorectal screenings, immunizations, and other types of preventive care.
- This care must be provided by a doctor who participates in your health plan.
You have the right to stay in your parent’s health plan if you are under 26 years of age.
Generally, you can be on one of your parents’ plans and stay on until your 26th birthday, even if you:
- got married
- Has or adopts a child
- Start or leave school
- Live with your parents or independently
- Not claimed as a tax dependent
- Declined coverage and was offered coverage at work
Insurance companies cannot limit annual or lifetime coverage of essential benefits.
Under this right, insurance companies cannot set a limit on the amount of money spent on essential benefits for as long as you are enrolled in the plan.
Essential health benefits are 10 types of services that health insurance plans must cover. Some plans cover more services, others may vary a bit by state. Check your health plan benefits to see what it covers.
Essential health benefits include:
- outpatient care
- Emergency services
- Hospitalization
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services
- prescription drugs
- Rehabilitation services and devices
- Chronic disease management
- laboratory services
- preventive care
- disease management
- Children’s dental and vision care (adult dental and vision care are not included)
You have the right to easy-to-understand information about your health benefits.
Insurance companies must provide:
- A Brief Summary of Benefits and Coverage (SBC) written in understandable language
- A glossary of terms used in healthcare and health coverage
You can use this information to compare plans.
You are protected from inflated insurance rate increases.
These rights are protected through the Rate Review and the 80/20 rule.
Rate Review means that an insurance company must publicly explain any rate increase of 10% or more before raising the premium.
The 80/20 rule requires insurance companies to spend at least 80% of the money they take from premiums for health care costs and quality improvement. If the company doesn’t, they may give you a discount. This applies to all health insurance plans, even grandfathered ones.
You cannot be denied coverage because you made a mistake on your application.
This applies to simple clerical errors or leaving information that is not necessary for coverage. Coverage can be canceled in case of fraud, premiums not paid, or paid late.
You have the right to choose a Primary Care Physician (PCP) from your health plan’s network.
You do not need a referral from your PCP to receive care from an OB/GYN. You also don’t have to pay more to get emergency care outside of your plan’s network.
You are protected against retaliation by your employer.
Your employer cannot fire you or retaliate against you if:
- You get a premium tax credit when you buy a health plan on the marketplace
- You report violations against the Affordable Care Act reforms
You have the right to appeal a decision by a health insurance company.
If your health plan denies or terminates coverage, you have the right to know why and to appeal that decision. Health plans must tell you how to appeal their decisions. If a situation is urgent, your plan must resolve it in a timely manner.
ADDITIONAL RIGHTS
Health plans in the Health Insurance Marketplace and most employer health plans must also provide:
- Lactation team and counseling for pregnant and lactating women
- Birth control methods and counseling (exceptions are made for religious employers and religious non-profit organizations)
