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Commentary – Patient Protection and Affordable Care Act Takes Effect

By Jessica DeMartino, PhD, Manager, Health Policy Programs

The NCCN Patient Advocacy Summit, held on September 23, 2010, coincided with the six-month anniversary of the enactment of the Patient Protection and Affordable Care Act and the effective date of several important provisions of that law.  Implementation of health care reform and its possible effects on the oncology community were the topics of an opening presentation and of subsequent roundtable discussion at the Patient Advocacy Summit.

Provisions that went into effect on September 23, 2010 include the following:

  • Insurers will no longer be able to:
    • Deny coverage to children with pre-existing conditions
    • Place lifetime limits on benefits
    • Cancel a policy retroactively without proving fraud
    • Deny claims without the chance for appeal
  • Consumers in new health plans will be able to:
    • Receive cost-free preventive services
    • Keep young adults on a parent’s plan until age 26
    • Choose a primary care doctor, ob/gyn, and pediatrician
    • Use the nearest emergency room without penalty

While these provisions seem straightforward and positive for patients, many of them have limitations that must be understood by patients and their physicians.  Several of these provisions do not apply to “grandfathered” health plans.  A grandfathered individual health insurance policy is a plan that an individual bought for himself or his family; that he did not receive through his employer; and that was issued on or before March 23, 2010.  Employer-sponsored health plans that were issued before March 23, 2010 can also be considered “grandfathered” for certain provisions.  Any type of health plan can lose its grandfathered status if it makes certain changes to the policy’s benefits or tries to significantly increase premiums, copays, or coinsurance requirements.  It is expected that a large majority of grandfathered health plans will lose their grandfathered status over the next few years and thus will be subject to certain provisions of health care reform.  The provisions that do not apply to grandfathered individual health plans are:

  • Denying coverage to children with pre-existing conditions, though this will extend to Americans of all ages starting in 2014
  • No lifetime limits on benefits


The following provisions do not apply to grandfathered individual and employer-sponsored insurance policies:

  • Receiving cost-free preventive services
  • Ability to choose a primary care doctor, ob/gyn, and pediatrician
  • Ability to use the nearest emergency room without penalty


Some of the provisions that went into effect on September 23 are of special interest to the oncology community.  Many young adults with cancer were previously unable to stay on his or her parents’ health plans or obtain insurance of their own.  They will now be able to remain on their parents’ health plans and continue to receive care.  While the oncology community is pleased with the removal of lifetime limits on benefits, concern was expressed at the Summit that annual caps still exist and were not addressed in health care reform.

 

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