Are annual or lifetime benefit limits allowed under ACA-compliant plans, and if not, what replaced them?

• A. ACA-compliant plans do not impose annual or lifetime limits on essential health benefits; no lifetime limits for EHBs.
• B. Annual limits are allowed.
• C. Lifetime limits are allowed.
• D. There is no regulation on limits.

Answer: (A)

Under ACA-compliant plans, there are no annual or lifetime dollar limits on essential health benefits. This protection prevents insurers from capping the care you can receive for core health services.

What replaces them is the annual out-of-pocket maximum. Each year, you pay up to this limit for covered essential health benefits (through deductibles, copays, and coinsurance); once you reach that cap, the plan covers 100% of those benefits for the rest of the year. The out-of-pocket maximum does not include premiums, and it may not apply to services outside the plan’s covered EHBs or to out-of-network charges in some cases.

So the correct understanding is that limits on essential health benefits themselves aren’t allowed, replaced by a yearly out-of-pocket cap that controls your total spending for those benefits.