QUESTION

I thought my employer plan couldn’t have any annual or lifetime limits on benefits but I heard that there may still be some limits in our plan. Is that allowed?

Individuals with coverage | Coverage for Employees of a Large Employer
ANSWER

All non-grandfathered group health plans are prohibited from imposing annual or lifetime dollar limits on “essential health benefits.” There may be some benefits that your plan covers that aren’t considered essential health benefits. For those services, your plan can include an annual or lifetime dollar limit. Plans can also include non-dollar limits on benefits, such as limits on the number of visits, or days in the hospital, even on essential health benefits.

Your Summary of Benefits and Coverage must include information on limitations and exceptions on services that are covered, as well as lists of excluded services and other covered services, which may include services that have greater restrictions and/or higher out-of-pocket costs than would apply to essential health benefits. (45 C.F.R. § 156.130; 45 C.F.R. § 147.200).


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