Essential Health Benefits/Annual Limits

[lrc14]

A self-insured health plan covers routine physical exams, including the cost of the office visit, and any associated labs, x-rays, immunizations, etc..., but subject to an annual dollar limit of $500. Anyone have any thoughts on whether the annual limit absolutely must be removed under PPACA? This type of service could obviously qualify as a preventive/wellness type service, which is one category of Essential Health Benefits, but I'm curious whether others know of any reasonable argument that the limit would not apply to this type of benefit. (I understand there are no regs yet, and that all of this is subject to reasonable, good faith, consistent interpretation until then).

[leevena]

The categories of essential health benefits are:

Ambulatory patient services

Emergency services

Hospitalization

Maternity and newborn care

Prescription drugs

Laboratory services.

You are missing; Mental Health/substance/behavioral, rehabilitattive and habilitative, preventive/wellness/chronic disease mgt, and pediatric.

[mruck]

§54.9814-2711(a)(2) Prohibits annual dollar limits on essential health benefits ("EHB"). Does this prohibition extend to treatment or service limitations on EHB or is the prohibition strictly a dollar limit prohibition? I have been unable to locate conclusive authority either way.

The Preamble to the final regulations, effective January 19, 2016, provide that group health plans not required to provide EHB may select among any of the 51 base-benchmark plans (which can be found here:

https://www.cms.gov/cciio/resources/data-resources/ehb.html )

The CMS website also states the following, the final sentence of the following excerpt causes me to think treatment and service limitations on EHB are permissible, but I am not 100% comfortable with this inference. Is any aware of binding authority or additional guidance?

"Because EHB benchmark plan benefits are based on plans that were sold in 2012 or 2014, some of the benchmark plan designs may not comply with current federal requirements. Therefore, when designing plans that are substantially equal to the EHB benchmark plan, issuers may need to conform plan benefits, including coverage and limitations, to comply with these requirements and limitations, including but not limited to the following:

... Annual and Lifetime Dollar Limits

The EHB benchmark plans displayed may include annual and/or lifetime dollar limits; however, in accordance with 45 CFR 147.126, these limits cannot be applied to the essential health benefits. Annual and lifetime dollar limits can be converted to actuarially equivalent treatment or service limits."