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Consumer Rights & Protections

Whether you need health coverage or have it already, the health care law offers new rights and protections that make coverage fairer and easier to understand. These rights and protections apply to all Marketplace and SHOP plans.

The new rights and protections also apply to most individual and small group plans sold by insurers outside of the Marketplace. However, they do not apply to health plans created or bought before March 23, 2010, which are known as grandfathered plans. Check your plan’s materials or ask your employer or benefits administrator to find out if your health plan is grandfathered.

Requires insurance companies to cover people with pre-existing health conditions
Insurers can’t deny you or charge you more for having pre-existing conditions like asthma, back pain, diabetes or cancer, assuming that these treatments are covered by the plan.
Requires insurance companies to cover Essential Health Benefits
All plans must cover health services within at least the following 10 categories: emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; ambulatory patient services; and pediatric services, including oral and vision care.
Limits out-of-pocket spending and cost-sharing
All plans must limit total consumer cost-sharing on deductibles, co-insurance, and co-pays on in-network covered services. Some consumers will be eligible for even more help with cost-sharing based on their income. In some cases, this can greatly reduce or even eliminate their deductible.
Helps you understand the coverage you’re getting in plain language
Insurance companies and group health plans must provide you with a short, plain language “summary of benefits of coverage.”
They are also required to use a uniform glossary of terms used in health coverage and medical care. This will allow you to make comparisons when looking at different plans.
Holds insurance companies accountable for rate increases
Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium.
The Medical Loss Ratio (80/20 Rule) generally requires insurance companies to spend at least 80% of the money they take in on premiums on your health care and quality improvement activities instead of administrative, overhead, and marketing costs.
Insurance companies that do not meet MLR standards established by ACA for individual, small group, and large group policies, must issue rebates to policyholders on the plan.
Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
The new law only allows cancellation of your policy if you don’t pay your premiums or if there is fraud involved.
Protects you choice of doctors
You have the right to choose the doctor you want from your health plan’s provider network.
You also can use an out-of-network emergency room without pre-authorization or penalty if you are facing an emergency situation and the nearest hospital that can stabilize your condition happens to be an out-of-network emergency room, or has some providers who are out-of-network in the emergency room. Likewise women can go to an OBGYN without a referral.
Covers young adults under 26
If your parents are on an employment plan and dependent coverage is offered, you may stay insured under your parents’ plan until you are 26, even if you’re married, not living with your parents, attending school, financially independent or eligible to enroll in your employer’s plan. However, married dependents’ spouses and/or children are not covered under the dependent’s parent’s plan.
Provides free preventive care
You may be eligible for free preventive screenings, like blood pressure and cholesterol tests, mammograms, colonoscopies, and more. This includes coverage for vaccines and new preventive services for women. These free preventive services will only be free if you use an in-network provider to perform the services. However, if your plan is grandfathered, you may have to pay a deductible, copay, coinsurance, etc. for certain preventive services.
Ends lifetime and yearly dollar limits on coverage of essential health benefits
Insurance companies can’t set a dollar limit on what they spend on essential health benefits for your care during the entire time you’re enrolled in that plan.
Marriage Equality
The Affordable Care Act requires all insurance companies to offer the same coverage to same-sex spouses as they do for opposite-sex spouses. This means that married same-sex couples and their children can enroll in a plan together and may qualify for financial help on the Health Insurance Marketplace.