Notice Requirement: Plans were required to give written notice that the lifetime limit on the dollar value of all benefits no longer applies and that an individual, if previously covered but had their coverage terminated due to hitting the lifetime limit, was once again eligible for benefits under the plan. Additionally, if the individual was not enrolled in the plan, or if an enrolled individual was eligible for but not enrolled in any benefit package under the plan, then the plan must have also given such an individual an opportunity to enroll that continued for at least 30 days (including written notice of the opportunity to enroll). The notices and enrollment opportunity must have been provided beginning not later than the first day of the first plan year beginning on or after September 23, 2010. ×
Note: Effective for plan years beginning on or after September 23, 2010; applies to both grandfathered and non-grandfathered plans.

A group health plan may not establish any lifetime dollar limit or annual dollar limit on benefits that are considered essential.

Under Section 1302(b) of the Affordable Care Act, "Essential Health Benefits" (abbreviated “EHB”) refers to benefits in the following 10 categories:

  1. Ambulatory patient services (e.g. outpatient care)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health services and addiction treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive services, wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Visit limits and day limits are still acceptable. Additionally, benefits that are considered non-essential can still have dollar limits.

The regulations require non-grandfathered plans in the individual and small group markets to cover all EHB’s. Large group plans and self-funded health plans are not required to cover all EHB’s. However, if they cover any benefits defined as an EHB, an annual or lifetime dollar limit cannot be imposed.

The regulations also require the states to define EHB’s for policies issued in that state. To meet this requirement, each state selected an existing health plan as a “benchmark” to establish services. Therefore, when a self-funded plan needs information on deciding what classifies as an EHB, a state benchmark plan should be used. The benchmark plan chosen can be from any state but it is best to choose one that provides benefits similar to the employer’s plan. Currently, Utah seems to have the least burdensome benchmark plan.

Additional information on benchmark plans can be found at: https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html