ACA Provisions

Restricted Annual Lifetime Limits

Insurers used to be allowed limit the amount of care people could receive both annually and in their lifetime, causing great financial hardship to people fighting serious or chronic illnesses. The ACA raises the ceiling on those limits - and will eventually prohibit them. The ACA prohibits all health plans from imposing lifetime dollar limits on essential health benefits. In addition, the law restricts health plans' ability to impose annual limits on the dollar value of essential benefits (and eventually prohibits annual limits starting January 1, 2014). The restriction applies to all new plans and grandfathered group plans, but not to grandfathered individual plans. HHS has phased in the restriction on annual limits over three years. Beginning September 23, 2010, health plans cannot impose an annual limit of benefits of less than $750,000. In 2011, the limit can't be less than $1.25 million, and in 2012 and 2013, it can't be less than $2 million.  In 2014, health plans cannot impose any annual limit at all. However, the ACA allows HHS to waive the restrictions on annual limits if a health plan or employer can show that this change would result in a significant increase in premiums or significant decrease in access to benefits. Since the annual limit restrictions went into effect in September 2010, HHS has granted hundreds of one-year waivers to employers and health plans who claimed that increasing the annual limit would result in substantial premium increases or loss of benefits for enrollees.

While the ACA bans monetary lifetime limits and restricts monetary annual limits, health plans can continue to impose non-monetary limits, such as limits on the number of physician visits, days in the hospital, and prescription drug refills.

The lifetime and annual limit requirements apply to the benefits covered in the minimum essential benefits package, which HHS will define in future regulations. If a service is not included in the essential benefits package, then the prohibition on lifetime and annual limits does not apply to it. However, some health plans, such as self-insured employer plans and grandfathered plans, do not need to provide the essential benefits package. HHS has said that self-insured plans and employers must make good faith efforts to define basic benefits for these plans consistent with the categories for essential benefits in the law.

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