Limiting the Limits: An Affordable Care Act Updat

By Emily McKinley, Health Information Specialist

The Affordable Care Act (ACA) continues to unfold provisions meant to ensure all Americans have adequate health coverage. Two provisions of the act are aimed at increasing the coverage provided by insurers while limiting out-of-pocket expenses to families. The first such provision eliminated lifetime limits insofar as insurance payments for essential benefits are concerned. The second provision introduced a phased implementation eliminating annual insurance payment limits for essential benefits.

Lifetime dollar limits for essential benefits were eliminated for coverage years beginning on or after September 23, 2010. This provision of the ACA applies to all insurance policies, regardless of whether they are employer-sponsored plans or individual insurance plans.

Also in 2010, the ACA commenced a phased implementation of the elimination of annual dollar limits. This implementation takes a stepwise approach for all job-related and individual plans purchased after March 23, 2010. Individual plans purchased before that date may be “grandfathered” and may not have the same provisions insofar as annual dollar limits are concerned. Consumers who purchased individual plans before March 23, 2010, are advised to check with their insurer to determine whether their plan adheres to these new benefit provisions. The provision regarding annual dollar limits regulates insurance payments for essential benefits.

Annual dollar limits paid by insurance plans will gradually be eliminated in the following manner. For coverage years beginning September 23, 2010 through September 22, 2011, annual limits were increased to no less than $750,000 per coverage year. For coverage years beginning September 23, 2011 through September 22, 2012, annual limits must meet or exceed $1.25 million per year. Plan years beginning September 23, 2012 through December 31, 2013, will carry annual limits no less than $2 million per year. Finally, for plan years beginning on or after January 1, 2014, annual dollar limits will no longer be legal.

All insurance and health care coverage plans will be able to maintain both lifetime and annual dollar limits for benefits not deemed essential by the Department of Health and Human Services (HHS). While a more specific definition is currently being drafted by the HHS, the ACA defines essential benefits to “include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.''

Once HHS releases the essential benefits definition draft, a public comment period will allow individuals, families, professionals, and others the opportunity to provide feedback and voice concern regarding the definition of such benefits. As always, Family Voices will strive to keep the families we serve informed of any new information pertaining to the ACA, essential benefits, public comment periods and other opportunities for advocacy.

For more information about the Affordable Care Act, please visit: www.healthcare.gov.

To view press releases regarding the ACA, please visit: http://www.hhs.gov/news/index.html.

To learn more about how these and other policy changes affect you, please contact Family Voices at info@fvindiana.org.