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Health Plan :Limits Hospital Benefits to $1,800 a Day

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A group health plan provides for all of the categories of benefits under essential health benefits. An employee covered under such plan was hospitalized for two days in connection with surgery. He had made a $1,000 copay payment at the time he was admitted to the hospital. The participant also obtained pre-authorization for the hospitalization, as required by the plan. After he was discharged, he found that he was subject to a bill of just under $50,000 for his hospitalization. The plan provides for a $1,800 per day limit on reimbursement of hospital expenses. His plan paid $3,600 ($1, 800 per day) for the two days of his admission and after applying his copayment. Since hospitalization is one of the essential health benefit categories, I am concerned that this is in violation of the ACA prohibition on annual limits. Hospitalization, per the SPD, includes the following: semi-private room and board, use of operating and recovery rooms and equipment; use of intensive care and equipment, laboratory or pathological exams, x-ray exams, drugs and medicines provided by the hospital; blood transfusions and use of transfusion equipment; use of cardiographic equipment and supplies, basal metabolic exams, anesthesia supplies and equipment, oxygen and its administrationi, use of physiotherapeutic equipment and supplies and any additional  medically necessary services and supplies customarily provided by the hospital. I am concerned that the $1,800 per day limit violates the prohibition on annual limits.  Does anyone agree?

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  • 2 months later...

If the group health plan is not an 'excepted' benefit plan (the mini-medical plans our President allowed to be sold again), and is subject to the ACA, the plan cannot impose annual or lifetime limits on essential health benefits. There is no way this plan would meet the minimum value requirements with a $1,800/day hospital limit.

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