Key cancer provisions in the Affordable Care Act

March 30, 2010

Approximately 160 provisions in the final health care legislation will directly impact the millions of Americans who have or will face cancer. The following is a list of the most important provisions for the cancer community:

I. Immediate Investments

• Provides immediate access to coverage for uninsured people with a serious pre-existing condition through high-risk pools (Sec. 1101)

• No lifetime limits for all plans; phase-out of annual limits by 2014 (Sec. 2711) • No rescissions except in the case of fraud or intentional misrepresentation (Sec. 2712)

• Coverage of preventive health services (beginning next plan year) (Sec. 2713) • Dependent coverage extended until age 26 (Sec. 2714)

• Reduction in Medicare Part D prescription drug coverage gap (i.e., the “doughnut” hole). (Sec. 3301-3315)

II. Enhancing the Role of Disease Prevention and Early Detection

• Guarantees coverage and eliminates out-of-pocket costs for U.S. Preventive Services Task Force (USPSTF) prevention services with an “A” or “B” rating, and mammography coverage for all women aged 40 and over. (Sec. 2713)

• Establishes a National Prevention Interagency Council and Strategy (Sec. 4001)

• Establishes a fund, to be administered through the Office of the Secretary at the Department of Heath and Human Services (HHS), to provide for an expanded and sustained national investment in prevention and public health programs (Sec. 4002)

• Grant funding for state, local and community-based prevention programs and services (Sec. 4201- 4202)

• Strengthens the primary care workforce through student financing, additional primary care residency programs at teaching health centers, and training in cultural competency, prevention, and public health (Sec. 5301-5605)

• Significantly increases community health center funding (Sec. 10503)

III. Meaningful Coverage: Availability, Affordability, Adequacy, and Administrative Simplification

A. Private insurance

Availability

• Provides immediate access to coverage for uninsured people with a serious pre-existing condition through the high-risk pool, affording a transition coverage until full implementation of the legislation (Sec. 1101)

• Eliminates pre-existing condition medical restrictions for most private insurance plans by 2014 (Sec. 2704)

• Prohibits all plans from rescinding coverage except in instances of fraud or misrepresentation (Sec. 2712)

• Guarantees availability and renewability of coverage (Sec. 2702-2703)

Affordability

• Limits insurance premium variation to family structure, geography, the actuarial value of the benefit, age (limited to a ratio of 3 to 1), and tobacco use (limited to a ratio of 1.5 to 1) (Sec 2701)

• Creates refundable tax credits to provide premium assistance for individuals and families up to 400% of the federal poverty level for coverage under a qualified health plan (Sec. 1401- 1415)

• Limits out-of-pocket maximums for individuals and families enrolling in qualified health plans (Sec. 1302)

Adequacy

• Eliminates lifetime and annual limits for most plans (Sec. 2711)

• Requires coverage of preventive health services (Sec. 2713)

• Requires insurance plans to cover essential health benefits (Sec. 1302)

Administrative Simplicity

• Develops and encourages utilization of uniform explanation of coverage documents and standardized definitions (Sec. 2715)

• Assists consumers with coverage appeals and educates consumers on their rights and responsibilities (Sec. 2719)

B. Medicaid

• Expands eligibility for individuals with income below 133% of the federal poverty level (FPL) and optional coverage for those above 133% of FPL (Sec. 2001)

• Generally prohibits states from reducing or dropping breast and cervical cancer treatment eligibility during transition period until 2014 (Sec. 2001)

• Increases access to tobacco cessation prescription medications and over-the-counter tobacco cessation products (Sec. 2502)

• Offers incentives for coverage of preventive services for eligible adults in Medicaid (Sec. 4106) • Mandates coverage of comprehensive tobacco cessation services for pregnant women in Medicaid (Sec. 4107)

• Permits states to use incentives to encourage enrollees to participate in chronic disease prevention programs (Sec. 4108)

• Simplifies enrollment in Medicaid (Sec. 2201-2202) • Improves Medicaid reimbursement rates for primary care physicians, fostering increased access for patients (Reconciliation Sec. 1202)

C. Medicare

• Begins immediate reduction in Part D prescription drug coverage gap (i.e., the “doughnut” hole) (Sec. 3301-3315)

• Improves Medicare coverage of annual wellness visit including a personalized prevention plan (Sec. 4103)

• Eliminates cost-sharing and deductibles in Medicare for USPSTF prevention services with “A” or “B” rating (Sec. 4104)

IV. Improving Quality of Life for Cancer Patients and Survivors

• Reauthorizes HHS’s Patient Navigator program, which assists patients with maneuvering through the health care system, provides outreach and education for patients to encourage preventive screenings, and addresses needs that may impact compliance with screening and treatment (Sec. 3510)

• Requires commercial health insurance plans and the Federal Employee Health Benefits Plan (but not private self-insured plans) to cover the patient care costs associated with participation in clinical trials that are approved or funded by a variety of federal agencies (Sec. 10103)

• Requires the Secretary of HHS to establish national priorities and plans for improving the quality of health care, including care coordination and chronic disease management (Sec. 3011-3015)

• Authorizes Institute of Medicine conference and report on pain management and enhanced coordination of NIH pain research, and establishes grant program to improve health professionals’ understanding and ability to assess and appropriately treat pain (Sec. 4305)

• Provides training grants in family medicine, general internal medicine, general pediatrics, physician assistantship, and geriatrics, giving priority to programs that apply team-based approaches to care (Sec. 5301)

• Expands career development awards to advanced practice nurses, clinical social workers, pharmacists, and psychologists (Sec. 5305)