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Is it true that under the ACA, insurers can’t cap how much they’ll pay out over the course of your lifetime?

  • November 1, 2015

Q. I have read that under the ACA insurers can not cap how much they will pay out over the course of your lifetime. Is this true?

A. Not entirely. They cannot impose a dollar limit on how much they reimburse for “essential health benefits.” (See a list of those benefits here.)  But they can cap how much they will pay out over the course of a person’s lifetime for specific benefits that are covered under your plans but are not considered essential benefits.

They can also place a limit on the number of visits the plan will cover, even for essential health benefits. For example, a plan might state that it covers 20 physical therapy visits per year. Even though physical therapy falls under the “rehabilitative and habilitative services” category of essential health benefits, carriers can limit the number of visits, as long as they don’t put a specific dollar limit on the benefit.

Read more FAQs about health reform, and essential benefits.

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