Health plans cannot set a lifetime dollar limit on "essential benefits" you receive. Essential benefits are things like hospital services, maternity care and prescription drugs. That means your coverage won't run out, even if you have a costly medical condition. Frequency and visit limits can still apply for some things like hearing aids and chiropractor visits.
Here's what's different
In the past, health plans set a lifetime limit. You were required to pay the cost of all care if you went over that limit.
How it impacts you
If you have a costly medical condition, the law makes sure your coverage won't run out during your lifetime.
If you've already reached a lifetime limit in your health plan and your health coverage ended because of it, you may be able to re-enroll when your plan year starts again. This option is available if:
- You had coverage through your job and you still work for the same employer (and the employer still uses that health plan), or
- If your family is still enrolled in the plan you had before (if your family purchased it directly from an insurer).
The health plan or your employer must tell you on or before the first day of the new plan year that there are no longer lifetime limits on your plan and that you are eligible for coverage. The health plan must give you at least 30 days to re-enroll.
I've already reached my lifetime maximum and my health plan stopped covering my medical bills. Can I re-enroll?
Yes. The health plan or your employer must tell you on or before the first day of the new plan year that there are no longer lifetime limits on your plan and that you are eligible for coverage. The health plan must give you at least 30 days to re-enroll.
I'm going to be having a baby. Can my health plan apply a lifetime limit on maternity care?
No. The law protects limits on maternity care because it is an "essential benefit". Other essential benefits under the law include:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Can my health plan apply a lifetime limit apply on dental benefits?
Yes. Your plan can limit how much it will cover for adult dental care each year or over your lifetime. Under the law, adult dental care is a "non-essential benefit".
Is there a reform law that applies to annual limits?
Yes. Learn more about lifetime dollar limits.