Under the Affordable Care Act, health plans are prohibited from imposing lifetime dollar limits on which of the following?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under the Affordable Care Act, group and individual health plans may not impose lifetime dollar maximums on essential health benefits — the core package of services, such as hospitalization, prescription drugs, and maternity care, that individual and small-group plans must cover. An insured who needs costly essential health benefit treatment can never have benefits cut off because a lifetime dollar cap was reached; dollar limits remain permissible only for benefits that are not essential health benefits. The New York State Department of Financial Services enforces these federal protections against New York-licensed insurers.
Why the other options are wrong
- B) Elective cosmetic surgery is not an essential health benefit, so a plan remains free to place dollar limits on it.
- C) The prohibition on lifetime dollar limits is not tied to a provider's network status; it applies to essential health benefits however the care is delivered.
- D) The lifetime-limit prohibition applies broadly to health plans, including grandfathered group plans; it is not confined to grandfathered individual policies.
Memory hook
Lifetime caps are dead for essential health benefits: essential care can never max out.