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Publication #FCS7256

Understanding the Changes to the Patient’s Bill of Rights as a Result of the Affordable Care Act1

Deanna Andrews and Martie Gillen2

Introduction

The Affordable Care Act (ACA) is a legislative act that has provided individuals and families more choices related to healthcare insurances. The Affordable Care Act offers consumers new protections and benefits by creating a more defined Patient’s Bill of Rights. However, some plans written before March 23, 2010, were grandfathered in, so check your individual plans.

Legislative Changes to the Patient’s Bill of Rights Resulting from the ACA

80/20 Rule

Health insurance companies must spend 80% of every dollar consumers pay for their healthcare plan (commonly known as premiums) on health care coverage. In fact, if health insurance companies do not adhere to the 80/20 rule, then consumers may receive a rebate from their health insurance company.

Child Rider Ages

If your insurance plan covers children, then your children will be able to stay on your insurance plan until they are 26 years old. This benefit applies regardless if the child is married, not living in the same household as you, going to school, does not rely on you financially, or is able to join their employer’s health insurance plan.

Preexisting Conditions

Insurance companies cannot limit or deny coverage to anyone because of a health problem or disability that was present before applying for coverage. A health issue that occurred before you applied for health insurance is known as a “preexisting” condition.

Benefits Information

Health insurance providers and group health plans must offer consumers an easy-to-understand summary of their coverage and benefits. This will include a standardized Summary of Benefits and Coverage (SBC) and a glossary of common health insurance terms. This will help consumers understand, compare, and choose a plan that will fit their needs. Health plans are also not allowed to have a lifetime or annual dollar limit on services that are needed.

Cancellations and Appeals

Although insurance coverage cannot be canceled because of an honest mistake on the application, this does not mean other factors cannot cause a cancelation in coverage (HHS, 2014). This benefit does not cover intentionally falsified information, which refers to consumers purposefully giving information that is incorrect (HHS, 2014). Patients are also guaranteed the right to appeal their plan’s decision to deny payment; appealing can be done by asking the insurance company to review its decision or asking a neutral third party to review the decision (HealthCare, 2014).

Preventive Care

Consumers may qualify for preventive services that may help to keep them healthy at no charge. A full list of preventive care services can be found at http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html. Common services include alcohol misuse screening and counseling, cholesterol screening, immunizations, and sexually transmitted infection (STI) prevention counseling. Coverage of certain preventive services may be based on the consumer's age and/or gender.

ER Access and Choice of Doctor

As an insurance consumer, you are allowed to choose your primary care doctor or pediatrician from your health plan’s provider network, which includes companies that are able to provide health care services to health plan members. For example, you can select an OB-GYN from the provider network. This gives consumers the benefit of not needing a referral to see an OB-GYN. In addition, if ER access is needed in the case of an emergency, then consumers are allowed to use an ER outside of their health plan’s provider network without a referral. This means if someone gets sick or injured outside of his/her home state, then he/she can visit the ER, and health insurance will still provide coverage.

Additional Information

For additional information on the Affordable Care Act or to read the full law, visit http://www.hhs.gov/healthcare/rights/. For information about signing up or to sign up for coverage, visit https://www.healthcare.gov/how-do-i-apply-for-marketplace-coverage/.

References

U.S. Department of Health & Human Services (HHS). 2014. About the Law. http://www.hhs.gov/healthcare/rights/

HealthCare. 2014. How do I appeal a health plan decision? https://www.healthcare.gov/how-do-i-appeal-a-health-insurance-companys-decision/

Footnotes

1.

This document is FCS7256, one of a series of the Family, Youth, and Community Sciences Department, UF/IFAS Extension. Original publication date May 2014. Visit the EDIS website at http://edis.ifas.ufl.edu.

2.

Deanna Andrews, undergraduate student, Family, Youth, and Community Sciences; and Martie Gillen, assistant professor and Family and Consumer Economics for Older Adults specialist, Family, Youth and Community Sciences; UF/IFAS Extension, Gainesville, FL 32611.


The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other UF/IFAS Extension publications, contact your county's UF/IFAS Extension office.

U.S. Department of Agriculture, UF/IFAS Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Nick T. Place, dean for UF/IFAS Extension.