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lifetime maximum benefit (or maximum lifetime benefit)

What is a lifetime maximum benefit?

Lifetime maximum benefit – or maximum lifetime benefit – is the maximum dollar amount a health plan will pay in benefits to an insured individual during that individual’s lifetime.

The ACA did away with lifetime benefit maximums for essential health benefits. Policies issued on or renewing after September 23, 2010 are required to have no lifetime benefit maximums on any essential health benefits covered by the plan.

Grandmothered and grandfathered plans do not have to cover all of the ACA’s essential health benefits, and neither do large group plans (in most states, “large group” means employers with 51 or more employees, but in Colorado, California, Maryland, New York, and Vermont, it only includes employers with 101 or more employees). But for essential health benefits that are covered by these plans, there cannot be any dollar limits applied to the total lifetime benefits.

Related articles

As of April 2012, lifetime benefit maximums on essential health benefits were prohibited on all new and renewing student health plans. But self-insured student health plans do not have to conform to these rules.

All new individual and small-group plans have covered essential health benefits (EHBs) since 2014, and there cannot be dollar limits on the lifetime or annual benefit maximums for these benefits.

Colorado family's struggle with monumental health expenses will no longer include battle with insurance carriers over lifetime caps

Allowing insurers to impose benefit limits might help lower premiums, but would taxpayers, patients, and families be left holding the bag?