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Annual dollar limts on EHBs


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Question about permissible plan design under the ACA. As I understand it, annual dollar limits for essential health benefits are prohibited under the ACA. However, it has been suggested to me that it would be permissible to lower the coverage level after a certain limit is met.

For instance, prescription drugs would be covered 100% after a $5 copay for the first $20,000 in annual expenses, but only at 30% after $20,000. Any thoughts on this? I'd imagine that a plan couldn't cover at only 1% after $20,000 because that would be a de facto annual limit.

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If 1% after $20,000 is a de facto annual limit, why isn't 30% after $20,000 also a de facto annual limit? Both reduce coverage, but neither one limits the annual dollar amount.

Not saying you can do it, just curious about the reasoning.

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To tell you the truth, I'm not sure. (It wasn't my idea.) But my best guess is this: imagine drugs are covered at 80% before $20,000, 75% between $20,000 and $60,000 and say 70% after $60,000. Would that be an annual dollar limit or just stepped cost-sharing? After all, there's no total limit on the number of dollars the plan would cover. Does the annual dollar limit prohibition prohibit all stepped cost sharing?

On a side note, looks like we share the same initials. I'm sure this message board is big enough for the both

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I'm sure this message board is big enough for the both

The more gmk's, the merrier (assuming that's who I really am :ph34r: )

Couldn't find a direct answer to your question. I believe that if your plan's coverage meets or exceeds the state-specific EHB-benchmark plan's coverage (and you don't have a specific annual or lifetime dollar limit), you're probably OK.

http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html

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When you're talking about an annual limit, given the proposed design is a coinsurance, do you mean the cost sharing limit on EHBs as per PPACA section 1302©(1) and 45 CFR 156.130? Or do you mean some other form of annual cap on benefits?


Kurt Vonnegut: 'To be is to do'-Socrates 'To do is to be'-Jean-Paul Sartre 'Do be do be do'-Frank Sinatra

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