Consumer rights and protections

Definition

The Affordable Care Act (ACA) came into effect on September 23, 2010. It included certain rights and protections for consumers.These rights and protections help make health care coverage more fair and easy to understand.

These rights must be provided by insurance plans in the Health Insurance Marketplace as well as most other types of health insurance.

Certain rights may not be covered by some health plans, such as grandfathered health plans. A grandfathered plan is an individual health insurance policy purchased on or before March 23, 2010.

Always check your health plan benefits to be sure what type of coverage you have.

Information

RIGHTS AND PROTECTIONS

Here are ways that the health care law protects consumers.

You must be covered, even if you have a pre-existing condition.

You have a right to receive free preventive care.

You have a right to stay on your parent's health plan if you are under 26 years old.

Generally, you can join a parent's plan and stay on until you turn 26, even if you:

Insurance companies can't limit yearly or lifetime coverage of essential benefits.

Under this right, insurance companies can't set a limit on the money spent on essential benefits the entire time 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 your plan covers.

Essential health benefits include:

You have the right to receive easy-to-understand information about your health benefits.

Insurance companies must provide:

You can use this information to more easily compare plans.

You are protected from unreasonable insurance rate increases.

These rights are protected through 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 increasing your premium.

The 80/20 rule requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement. If the company fails to do so, you may get a rebate from the company. This applies to all health insurance plans, even those that are grandfathered

You can't be denied coverage because you made a mistake on your application.

This applies to simple clerical mistakes or leaving off information not needed for coverage. Coverage can be cancelled in the case of fraud or unpaid or late premiums.

You have the right to choose a primary care provider (PCP) from the health plan network.

You don't need a referral from your PCP to receive care from an obstetrician/gynecologist. You also don't have to pay more to receive emergency care outside of your plan's network.

You are protected against employer retaliation.

Your employer cannot fire you or retaliate against you:

You have the right to appeal a health insurance company decision.

If your health plan denies or ends coverage, you have a right to know why and to appeal that decision. Health plans must tell you how you can appeal their decisions. If a situation is urgent, your plan must deal with it in a timely manner.

ADDITIONAL RIGHTS

Health plans in the Health Insurance Marketplace and most employer health plans must also provide:


Review Date: 4/15/2018
Reviewed By: Linda J. Vorvick, MD, Clinical Associate Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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