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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


Policy Limits on Essential Health Benefits

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Question: My wife is 52 and is diagnosed bi-polar, paranoid schizophrenia, ptsd, multiple personalities and depression. She has been in psychiartric hospitals off and on since about 1995.The insurance I have at work changed around 2005 and now each family member has a lifetime cap of 50 days inpatient psychiatric. My wife hit her limit in november of 2011. She has been hospitalized twice since then. She never worked enough to get her minimum credits for social security and hasn’t worked much at all since 1979. I live in PA and was told I made too much money for her to get medicaid. The last hospital bill was for 28 days and costs about $25,000. Two months earlier it was 10 days and costs $9000. I don’t make enough money to pay these bills, I don’t want to abandon her or divorce her and sadly, she will probably have problems her whole life. Is there any help she can receive in the form of medical coverage for her psychiatric stays?

Answer: (Please take this to your HR Representative) The Affordable Care Act (ACA) prohibits the imposition of lifetime and annual benefit limits for essential health benefits. Mental health and substance abuse disorder services, including behavioral health treatment are included under essential health benefits. Federal regulations provide for a three-year phase-in period—September 23, 2010 to January 1, 2014—during which a group health plan or health insurer offering group or individual health insurance coverage may establish an annual limit on the dollar amount of benefits that are subject to specified dollar amounts. While any health plan or insurer offering group or individual health insurance coverage may establish a higher limit or impose no annual limits at all, the annual limit on essential health benefits for each of the three years may not be less than the following:

  • $750,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2010 but before September 23, 2011;
  • $1,250,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2011 but before September 23, 2012; and
  • $2,000,000 for plan years (policy years in the case of individual coverage) on or after September 23, 2012 but before January 1, 2014.

Group health plans must comply with the ACAs provisions prohibiting annual limits on essential health benefits—including the restricted phase-in limits— whether or not the plans are grandfathered.

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