Rights and Protection

The Affordable Care Act (ACA) guarantees a number of rights and protections for individual consumers that make coverage fairer and easier to understand. Following is a summary of those rights and protections.

Health Insurance Marketplaces (Exchanges)
The ACA created the Health Insurance Marketplaces (or Exchanges), a new way for individuals, families and small businesses to get health coverage.

No Pre-existing Condition Exclusions
The ACA requires insurance companies to cover people with pre-existing health conditions. For plan years beginning in 2014, health plans can’t turn down applicants or charge more because of sickness or a health condition. They also can’t charge women more than men. The only exception is for grandfathered individual health insurance plans.

Easy-to-understand Coverage
Consumers have the right to get an easy-to-understand summary about a health plan’s benefits and coverage. Insurance companies and group health plans must provide consumers with:

This information allows consumer to make “apples-to-apples” comparisons when looking at different plans.

All individual and group health plans must also use the same standard form to make it easier to compare plans. The SBC also includes details, called coverage examples, which show what the plan would cover in two common medical situations: diabetes care and childbirth. There’s a link to each plan’s SBC in the Marketplace.

Rate Review
Rate Review helps protect consumers from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10 percent or more before raising premiums. This does not apply to grandfathered plans.

The ACA prohibits insurance companies from canceling coverage just because of a mistake on an insurance application.

In the past, if an insurance company found a mistake on an insurance application, they could:

  • Take away coverage
  • Declare the policy invalid from the day it started
  • Ask to be paid back any money they had already spent for medical care

It’s now illegal for insurance companies to cancel coverage simply because of an honest mistake or missing information on an application that has little bearing on the applicant’s health. These protections apply to all health plans, including grandfathered plans, whether coverage is employer sponsored or not.

Insurance companies can still cancel coverage if an applicant purposely enters false or incomplete information on an insurance application. They can also cancel coverage if premiums are not paid on time.

Choice of Doctors
The ACA guarantees consumers the right to choose the doctor they want from their health plan’s provider network. It also gives them the right to use an out-of-network emergency room without penalty.

  • Pick any doctor: Consumers can choose any available primary care provider in their insurance plan’s network. They can also choose any available network pediatrician as their child’s primary care doctor.
  • No referrals needed for OB-GYN services: No referrals are needed from a primary care provider to get obstetrical or gynecological (OB-GYN) care from a specialist.
  • Access to out-of-network emergency room services: Insurance plans can’t require higher copayments or coinsurance for emergency care from an out-of-network hospital. They also can’t require prior approval before getting emergency room services from a provider or hospital out of network.

These rights don’t apply to grandfathered plans.