maximum-benefit dollar limit

What is a maximum benefit dollar limit?

The maximum benefit dollar limit refers to the maximum amount of money that an insurance policy will pay for claims within a specific time period. This can refer to an overall policy maximum, or a maximum for a specific type of care.

Maximum benefit dollar limits used to be commonplace among major medical health plans, but the Affordable Care Act (ACA) eliminated them in most cases for essential health benefits. Grandfathered plans can still have annual maximum benefit dollar limits, but not lifetime limits. All other plans that are regulated by the ACA are prohibited from having lifetime or annual maximum benefit dollar limits on any essential health benefits.

Plans that are not regulated by the ACA, such as short-term health insurance and Farm Bureau plans in some states,¹ can and do still impose annual and lifetime limits on how much they will pay for a member’s care.