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Hereditary Cancer Info > Privacy & Legal Issues > Patient Protection and Affordable Care Act (PPACA)

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Patient Protection and Affordable Care Act (PPACA)

There are laws that protect the rights of people with an inherited mutation or hereditary cancer.

Coverage for screening and preventive services

The PPACA requires health plans to pay for certain screening without any out-of-pocket costs to patients. 

Mammograms

The Affordable Care Act requires insurance companies to pay for mammograms with no out-of-pocket expenses for women ages 40 and older. However, the law does not apply to women below age 40, and it covers, at most, one test per year. Most insurance companies will cover the cost of mammograms for high-risk women below age 40 as recommended by national guidelines. Some out-of-pocket cost may be required. 

Tamoxifen or raloxifene to lower cancer risk

The Affordable Care Act requires insurance companies to pay for tamoxifen or raloxifene with no out-of-pocket expenses for women ages 35 and older who meet the United States Preventive Services Task Force (USPSTF) guidelines. However, the laws do not apply to women below age 35 and some high-risk women may not be eligible, even if they have a BRCA mutation. 

Genetic counseling and testing

Under the Affordable Care Act, insurance companies are required to pay for both genetic counseling and BRCA testing for women who meet certain criteria. For these patients, insurance companies must cover the entire cost of genetic counseling and BRCA testing with no out-of-pocket costs to the individual. 

The Affordable Care Act regulations do not cover the following situations:

  • genetic counseling and testing in people who do not meet United States Preventive Services Task Force (USPSTF) guidelines
  • genetic counseling or testing in people with a family history indicative of Lynch Syndrome (associated with colon, uterine, and ovarian cancer) or other hereditary cancer syndromes
  • genetic counseling and testing in men
  • panel testing or testing for genes outside of BRCA1 and BRCA2

Even in situations that are not covered under the Affordable Care Act, health insurance often covers the costs of these preventive services, however, there may be a co-pay or deductible fee to the patient. 

The Center for Consumer Information and Insurance Oversight (CCIIO) at CMS is the agency consumers can contact for help when they feel they have been inappropriately denied services or were inappropriately charged a co-pay or deductible counter to the Patient Protection and Affordable Care Act. They run a helpline at (887) 267-2323 ext. 6-1565, or can be reached by email at: phig@cms.hhs.gov

updated 05/25/16

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