Key Protections of the Affordable Care Act

By Lisa Yagoda, Nicole Duritz, Joan Friedman

Copyright © 2014 AARP. All rights reserved.

The Affordable Care Act (ACA) offers protections for everyone. For example, the ACA requires that insurance companies selling to individuals and small employers do the following:

  • Fully cover certain preventive care services, such as cholesterol and blood pressure screenings, mammograms, colonoscopies, and recommended immunizations. For such services, you shouldn’t pay a copayment or coinsurance payment, and you should get them free even if you haven’t met your plan deductible.

    Note, however, that you may encounter costs related to a service — for example, a facility or office fee — even if there is no cost to you for the screening test itself. And if the screening results in diagnostic services – for example, the doctor finds polyps during a routine colonoscopy – you may be charged for their removal and biopsy.

    However, if you have coverage through a large group plan or if your insurance plan is grandfathered, you may not get this preventive coverage.

  • Allow you to select your doctor (and your children’s doctor) from your plan’s provider network.

  • Allow you to seek care from an OB-GYN without a referral from your primary care provider.

  • Let you get care from an out-of-network emergency room service without paying a higher copayment or coinsurance payment than you’d pay in network. (This way, you don’t have to pay higher costs for getting emergency care out-of-network if you’re away from home and need emergency care. But the out-of-network provider may still be able to bill you if the amount your plan pays is less than its charges.

  • Provide coverage on a parent’s family plan for adult children under age 26, even if they are married, not living with their parents, eligible to enroll in a plan at work, or financially independent.

    Note: Employers are not required to offer family plans. Check with your employer first to see if it does.

    This provision aims to reduce the number of uninsured young adults and ease parental worries. In the past, young people were typically forced off their family’s health plan upon turning 18 or 21 or when graduating from college.

  • Share publicly its reasons for raising your premiums more than 10 percent, and get approval for doing so from the state insurance commissioner. This protection is called rate review.

  • Spend at least 80 percent of the premiums they collect to pay for healthcare and quality improvement. Only 20 percent (or less) of premiums collected should be spent on a company’s administrative, marketing, and overhead costs. If the company doesn’t hit this ratio in a plan year, it could possibly owe its customers a rebate for a portion of the premiums they paid.

    This rebate may come in the form of a rebate check, a lump sum deposit to the account you used to pay the premium, or a reduction on future premiums. If the rebate goes to your employer, your employer can pass it along in any of these same ways or use it to improve your coverage.

  • Give you a Summary of Benefits and Coverage (SBC), which is a document that spells out your benefits and coverage in language that is easy to understand. All SBCs must follow a standard outline. That way, if you’re shopping for insurance coverage, you can look at two or more SBCs and do an apples-to-apples comparison.

    If you’re already insured and your insurance company hasn’t yet given you an SBC for your current plan, call or e-mail the company to ask for one. If you have an employer-sponsored plan, ask your human resources department or benefits administrator for the SBC. You can also request a glossary that companies must provide to help explain healthcare and medical terms.

  • Offer you the right to appeal its decisions, such as the denial of a claim. In its paperwork noting such a decision, the insurer must explain why it denied the claim and explain your right to appeal. If you request that the company reconsider such a decision, your insurer must do so.

    If the decision stands, you have the right to request a review by an independent organization that then determines whether to accept or overturn the insurer’s decision.