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:
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