Lifetime Limits Explained

Prior to the passage of the Affordable Care Act, your insurance company could set a lifetime limit, which is a dollar limit on how much your insurance company would spend on your covered benefits. Any care that went beyond those limits would be paid for out of pocket. This came as a devastating blow to individuals requiring intensive medical treatment such as surgery or cancer treatment, as the dollar amount attached to such a medical procedure is very high.

The current law prohibits lifetime limits on the 10 essential health care benefits (outpatient care, inpatient care, maternity/newborn care, rehabilitation services/devices, prescriptions, and emergency, mental health/addiction, lab, preventive, and pediatric services). As a result, individuals now have access to medical care and treatment without having to worry about going over their limit. However, your plan still requires a deductible, which is the amount you pay each year before your insurance starts paying.

While lifetime limits are not allowed for essential services in any state, lifetime limits for non-essential services will vary by both state and insurance plan. Examples of non-essential services are acupuncture, cosmetic surgery, nursing home care, and dental/vision/hearing.

However, keep in mind that there are exceptions to the exceptions. For example, your insurance would cover reconstructive surgery after a mastectomy, as it is considered medically necessary, but wouldn’t cover a nose job because you don’t like the shape of your nose. When you are shopping around for insurance, make sure to take lifetime limits into consideration, as a low lifetime limit could cost you in the long run.

Ultimately, as of the current insurance laws and regulations, individuals continue to have unrestricted access to essential health services without fear of lifetime limits. Changes may be on the horizon, but for now, your insurance plan will remain the same.