The Affordable Care Act (sometimes called the ACA or “Obamacare”) made significant changes to the U.S. health insurance system—and includes significant anti-discrimination provisions. Make sure you understand your rights under the ACA and other laws.
The ACA’s anti-discrimination rules mirror other federal laws, like the Civil Rights Act and the Age Discrimination in Employment Act. Section 1557 of the Affordable Care Act prohibits discrimination due to race, color, national origin, sex, age, or disability. A health insurer or medical provider also cannot use neutral policies that disparately impact members of a protected class.
Section 1557 covers a variety of health programs and activities, including:
- Any program or institution that gets funding from HHS (including Medicare or Medicaid),
- Any program administered by HHS, and
- Health Insurance Marketplaces and insurers that participate in the Marketplaces.
In other words, it covers most insurance plans, medical providers, hospitals, and retail pharmacies. However, some job-based health insurance plans are “grandfathered,” and are not covered by the ACA.
Other insurance laws, rules, and regulations may also apply, including the:
- Employee Retirement Security Act (ERISA), and the
- Health Insurance Portability and Accountability Act (HIPAA).
These laws provide additional protections and may require different complaint procedures. If you have been discriminated against, you should contact a lawyer for assistance. A health insurance lawyer can help you identify all of your causes of action and file the correct paperwork and claims.
Can Health Insurance Companies Legally Refuse to Insure a Patient?
Under federal law, you cannot be denied insurance due to:
- A pre-existing condition or health status,
- Race or color,
- National origin,
- Age, or
According to HHS, gender identity is also protected. In fact, transgender patients have been on the forefront of Section 1557 litigation.
A pre-existing condition is a medical condition that existed before your enrollment in a health insurance plan. Under the ACA, pre-existing conditions (including pregnancy and chronic conditions) must be immediately covered by the insurance plan.
Additionally, an insurance company cannot deny coverage, refuse essential health benefits, or cancel a policy for discriminatory reasons. Under the ACA, you have the right to appeal a denial of coverage. You may either file an internal appeal with the insurance company or an external appeal with a state or federal agency. If you need help filing an appeal, consider hiring a health insurance lawyer. A lawyer can help you file the correct appeal and build a persuasive case for coverage.
Can Health Insurance Companies Charge Patients Different Premiums or Rates?
Similarly, insurance companies cannot charge you more due to your race, national origin, gender or a pre-existing condition. However, premiums may be increased because of:
- Age: older people may be charged three times the rates of younger policyholders,
- Tobacco use: smokers may be charged 50% more than non-smokers,
- Family size: Individuals may be charged less than those with dependents or families, and
- Geography: insurance companies may factor in your community’s health care costs when setting rates.
Health insurers must also justify certain rate increases. If you have questions about the legality of your insurance premiums, consider contacting an insurance benefit lawyer.
How Can I File a Health Insurance Discrimination Claim?
If you are illegally discriminated against, you may file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Typically, you must file your complaint within 180 days of the discriminatory act (unless you can show good cause for a late filing). You also have the right to file a lawsuit against the insurance company or other institution.
Health insurance discrimination law is still developing. The ACA was enacted in 2010, and the HHS formalized its anti-discrimination rules in 2016. The federal courts have not handled many ACA discrimination claims yet—leading to uncertainty about how the law should be applied.
Can a Lawyer Help My Case?
Yes. Because of the uncertainty in the growing field, it may be best to speak with an insurance lawyer. A lawyers can help you understand your rights, file the correct paperwork and claims, and keep you updated on legal developments.