If a plan imposes an annual or lifetime limit on specific benefits, are amounts paid by covered individuals after satisfying the deductible treated as out-of-pocket expenses under section 223?
A-15. The out-of-pocket maximum in section 223©(2)(A) applies only to covered benefits. Plans may be designed with reasonable benefit restrictions limiting the plan’s covered benefits. A restriction or exclusion on benefits is reasonable only if significant other benefits remain available under the plan in addition to the benefits subject to the restriction or exclusion.Example 1 . In 2004, a self-only health plan with a $1,000 deductible includes a $1 million lifetime limit on covered benefits. The plan provides no benefits for experimental treatments, mental health, or chiropractic care visits. Although the plan provides benefits for substance abuse treatment, it limits payments to 26 treatments per year, after the deductible is satisfied. Although the plan provides benefits for fertility treatments, it limits lifetime reimbursements to $10,000, after the deductible is satisfied. Other than these limits on covered benefits, the plan pays 80 percent of major medical expenses incurred
A-15. The out-of-pocket maximum in section 223©(2)(A) applies only to covered benefits. Plans may be designed with reasonable benefit restrictions limiting the plan’s covered benefits. A restriction or exclusion on benefits is reasonable only if significant other benefits remain available under the plan in addition to the benefits subject to the restriction or exclusion. Example 1 . In 2004, a self-only health plan with a $1,000 deductible includes a $1 million lifetime limit on covered benefits. The plan provides no benefits for experimental treatments, mental health, or chiropractic care visits. Although the plan provides benefits for substance abuse treatment, it limits payments to 26 treatments per year, after the deductible is satisfied. Although the plan provides benefits for fertility treatments, it limits lifetime reimbursements to $10,000, after the deductible is satisfied. Other than these limits on covered benefits, the plan pays 80 percent of major medical expenses incurred
Related Questions
- If a plan imposes an annual or lifetime limit on specific benefits, are amounts paid by covered individuals after satisfying the deductible treated as out-of-pocket expenses under section 223?
- Can a health plan that imposes a lifetime limit on benefits still qualify as a high-deductible health plan?
- Does the law limit lifetime or annual caps on individual benefits?
