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Can Self Insured Health Plan cap payments for air ambulances, or is it prohibited from doing so under ACA?


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Self insured plan wants to cap payments made for air ambulances to some arbitrary number, $20,000 for example. Does it matter that this is for emergency care, and is this a essential health benefit under the ACA? Any source you can point do would be appreciated. Thank you!

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39 minutes ago, leevena said:

Self funded plans are not subject to essential health benefits.  Yes the plan sponsor can do this.  

Yes, emergency services are an essential health benefit.

Thank you taking the time to respond, but I do have an additional question: from researching I found this explanation and would love to hear your opinion on it:            

""Self-funded plans are not required to cover “essential health benefits.” Nevertheless, the definition of “essential health benefits” has implications for all employee health care benefit plans because, to the extent that such plans offer benefits that are considered “essential,” they are prohibited from imposing lifetime or annual dollar limits on such benefits."

So, assuming my self funded plan currently does offer emergency/ambulatory services, then, despite the fact that they are not required to cover essential health benefits, they are nevertheless prohibited from enacting the 20k coverage limit because they currently offer the ambulatory/emergency benefit that is deemed "essential." Would you agree with this analysis? Thank you again for your time. 

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HHS decided to not provide a definitive definition of essential health benefits.  Therefore self funded plans can use a definition based off of the state they are in, or operate in.  Since states have different benchmarks and definitions of what is essential it makes it possible for limits like this one.  

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Self-funded plans are not required to cover essential health benefits (EHBs), but if they do, they cannot place dollar limits on them. However, the air ambulance can be capped, because it is not clear that it is considered an EHB (unlike normal ambulance transport coverage). There is mention of Air Ambulance services in the ACA, but not relative to benefits - only in regard to payments/allowable rates for those services.  My colleagues and I interpret this to mean a self-funded plan could place limits on the benefit with a maximum per trip amount.  Of course, even if this was an EHB, I would look at the state benchmark plans to see if any of them have limitations on air ambulance services. If one does, a self-funded plan is allowed to follow the benchmark of any state, as long as their benefits are consistent with that state, they remain in compliance.  Some commenters requested clarification as to whether air ambulance transport and other emergency transportation is within the scope of the term “emergency services.” The Departments decline to provide a rule addressing this issue. These final regulations continue to provide that the terms emergency medical condition, emergency services, and stabilize have the meaning given to those terms under EMTALA, section 1867 of the Social Security Act.[88] - https://www.federalregister.gov/documents/2015/11/18/2015-29294/final-rules-for-grandfathered-plans-preexisting-condition-exclusions-lifetime-and-annual-limits

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