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ObamaCare Clusterfuck: "Per beneficiary" limits a loophole insurance companies can drive a truck through?

ObamaCare defenders consistently point to caps on dollar costs as one of the main benefits of ObamaCare. However, via Michael Olenick, from ObamaCare Facts ("dispelling the myths") we read this:

While you may have to meet a certain amount of out-of-pocket expenses (deductible) before essential benefits are covered, the Affordable Care Act prohibits health plans (grandfathered and non-grandfathered) from imposing annual and lifetime dollar limits on essential benefits.

So far so good. Now get this:

Health plans can still however set limits on the number of times you can receive a certain treatment.

Hmm. How can this be? Let's go to the text of the statute; I'm guessing 42 U.S. Code § 300gg–11 - No lifetime or annual limits:

(a) Prohibition
(1) In general
A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—
(A) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
(B) except as provided in paragraph (2), annual limits on the dollar value of benefits for any participant or beneficiary.
(2) Annual limits prior to 2014
With respect to plan years beginning prior to January 1, 2014, a group health plan and a health insurance issuer offering group or individual health insurance coverage may only establish a restricted annual limit on the dollar value of benefits for any participant or beneficiary with respect to the scope of benefits that are essential health benefits under section 18022 (b) of this title, as determined by the Secretary. In defining the term “restricted annual limit” for purposes of the preceding sentence, the Secretary shall ensure that access to needed services is made available with a minimal impact on premiums.

That's the dollar cap. Here's the loophole:

(b) Per beneficiary limits
Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage from placing annual or lifetime per beneficiary limits on specific covered benefits that are not essential health benefits under section 18022 (b) of this title, to the extent that such limits are otherwise permitted under Federal or State law.

OK, what are these "essential health benefits"? As it turns out, depending on your situation, they may not be all that essential. From the Glossary at healthcare.gov:

Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Well, as I read that, something like expensive chemo treatment is not on the "essential benefits" list, because of course ObamaCare isn't about what's essential to you, but about what's essential to get insurance companies to participate in the exchanges.

How would per beneficiary limits work out in practice? From UnitedHealthCare, in their "Annual Limits" Section:

Are plans allowed to have annual visit or day limits?
The Department of Labor (DOL) has informally commented [!!] that frequency limits are generally acceptable. Such limits, however, should not "transcend" into dollar limits. For example, a frequency limit of 10 visits alone may be acceptable, but if the plan also places a cap on reimbursement, such as $50 per visit, the net result would be a $500 annual limit. In such cases, the DOL suggested that tying the payment to reasonable and customary expenses, or similar action, may rectify the annual limit issue.

And again:

Can plans replace dollar limits with visit or other limits in high risk cases?

The question of whether plans will be allowed to have annual visit or day limits are not directly addressed by the law or the interim final rules. The DOL has informally commented that frequency limits are generally acceptable. Such limits, however, should not "transcend" into dollar limits. For example, a frequency limit of 10 visits alone may be acceptable, but if the plan also places a cap on reimbursement, such as $50 per visit, the net result would be a $500 annual limit. In such cases, the DOL suggested that tying the payment to reasonable and customary expenses, or similar action, may rectify the annual limit issue.

So, in other words, a frequency unit can be placed for types of non-"essential" care whose dollar costs are not given in the policy. But it seems to me that such are is exactly the kind of care that one would wish to insure against most, because it's the costliest and riskiest. If you need to rehab your hip, and that's going to take 20 visits, but the policy only covers 10, then you get to choose between being a cripple and a really big stack of bills. If you need chemo, and that's going to take 26 treatments, but your policy only covers 13, then you get to choose between the Big C and selling your house. And so forth. (Note that your hip and becoming cancer-free are essential to you, but that doesn't mean they're essential under ObamaCare.)

Readers, here I'm handicapped by my horrified unfamiliarity with actual insurance policies. Does this seem like a plausible interpretation? What does your policy say, if you have one?

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psychohistorian's picture
Submitted by psychohistorian on

Yes, I have a story related to this.

I got sideswiped at highway speed by a Chevy Avalanche in 2006 riding my bicycle....took off the side with the back of my head....and its a miracle I am here but that is another story.

So Kaiser patched me up pretty good until the insurance money ran out and then they said, Would you like morphine or Oxycontin for that pain....(sic)

I didn't like that answer and decided to go outside to continue my healing path. In the past 3 years I have spent $7, 9 and 15K respectively on healing.

In this past year one of my health providers talked with me about trying to get Medicare to pay for $1900 of treatment under one of the areas of coverage. That is when I found out that Kaiser must approve all outside Medicare charges because I have my Medicare supplemental with them. When asked if they would approve the charges to Medicare (NOT Kaiser) they said no because I had not come to them first.

I am worth every penny I have spent, have made remarkable improvement and innovated a breath exercise to resolve trauma, anxiety and stress associated with my TBI, PTSD and Anxiety Disorder afflictions. I am working now to finish my healing enough and evolve the breath exercise so that I can go to the VA and make my healing strategy available for our poor under served Vets with similar maladies.

My intention is to save the world, one breath at a time.

Onward!!!

psychohistorian's picture
Submitted by psychohistorian on

Here is the cleaned up version that I couldn't save for some reason....feel free to take out first one Lambert...

Yes, I have a story related to this.

I got sideswiped at highway speed by a Chevy Avalanche in 2006 riding my bicycle....took OFF the side mirror with the back of my head....and its a miracle I am here but that is another story.

So Kaiser patched me up pretty good until the insurance money ran out and then they said, Would you like morphine or Oxycontin for that pain....(sic) They also said I reached the limit of PT sessions associated with my problem(s).....just like in Lamberts description above.

I didn't like that answer and decided to go outside to continue my healing path. In the past 3 years I have spent $7, 9 and 15K respectively on healing.

In this past year one of my health providers talked with me about trying to get Medicare to pay for $1900 of treatment under one of the areas of coverage. That is when I found out that Kaiser must approve all outside Medicare charges because I have my Medicare supplemental with them. When asked if they would approve the charges to Medicare (NOT Kaiser) they said no because I had not come to them first.

I am worth every penny I have spent, have made remarkable improvement and innovated a breath exercise to resolve trauma, anxiety and stress associated with my TBI, PTSD and Anxiety Disorder afflictions as well. I am working now to finish my healing enough and evolve the breath exercise sufficiently so that I can go to the VA and make my breath healing strategy available for our poor under served Vets with similar maladies....stop/reduce the suicides, I hope.

My intention going forward is to save the world, one breath at a time.

Onward!!!

Health care should be a human right for ALL! Not limited by the fascist bean counters and plutocrats.

quixote's picture
Submitted by quixote on

That sure sounds like a massive loophole. If it wasn't, why would the InsureCos have carefully stuck it in there?

I suspect the justification is hypochondriac prevention. Without visit caps, zomg, people will just go to the doctor all the time for nothing instead of going to the beach, y'know.

But in practice it'll wind up being yet another way to filter out expensive patients, the few who managed to get care in spite of the narrow networks.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Your post evokes that BS talking point that -- by force of repetition and zero push back by anyone in a position to do so in the same media outlets where the BS talking points in chief are trumpeted and propagated -- Cost Shifting is Necessary to Incentivize Over Consumerism among people getting medical care.

Yes, because when was the last time you, me or anyone we know decided to go have a heart bypass just for the heck of it. Or a root canal Or chemo. Or dialysis. Or an amputation.

It baffles me that this idiocy that "costs are up because people are getting too much health care they don't need" hasn't been challenged with such elementary questions. Because that's really as deep as it goes.

Maybe time for slogans like: "When Was The Last Time Aetna Met a Policyholder Who Decided to Get Chemo For The Heck of It?"

Rainbow Girl's picture
Submitted by Rainbow Girl on

... IIRC it focused directly on the ACA statute's definition of what exactly counts towards expenses subject to the cap. And IIRC, we had a CW consensus that it appeared the statute was written so that insurers are perfectly free NOT to count towards the OUT OF POCKET MAX: premiums, copays, deductibles, you-name-it, leaving the question as to what exactly they were REQUIRED to count.

Submitted by lambert on

Spend the afternoon in the garden, or go to the doctor's office to get care I don't need?

Decisions, decisions.

* * *

Combine with the fear and horror of getting involved with the medical system and the finance system...

Rainbow Girl's picture
Submitted by Rainbow Girl on

Exactly. And how many soi disant educated americans listen to the talking point zombie-like without even two watts of skepticism lighting up somewhere in the over educated storehouse of their brain system.

And yeah, I'm really excited about having to go see the specialist about the knee that isn't getting better after 5 weeks, and pay out of pocket (uninsured) $1K for the whole thing assuming he has to give me a cortisone injection. I'm doing a lot of mind over matter meditation (as well as icing, elevation, rest and gobs of alleve) in the hopes that in 24 hours I won't need to see the doc, who happens to be excellent and a great person nonetheless.

Submitted by hipparchia on

this isn't new to obamacare, insurance companies have done this forever.

and not only that, but your policy may have a cap of, say, 60 rehab visits per year but the insurance company will pronounce you cured after 20 or so visits and refuse to pay for more. or your policy has a cap of 35 mental health visits per year but the insurance company pronounces you cured after 12 visits. etc...

Rainbow Girl's picture
Submitted by Rainbow Girl on

This brings into high relief that insurance companies are a mafia that simply collects your money and gives (near) nothing in return, because of these 10,000 techniques (all tethered to the deliberate Rube Goldberg complexities of "product design" (the policies)) to justify this one way predatory looting of the consumer/mark (former citizen).

Submitted by lambert on

Here I'm handicapped by my blissful ignorance of how to, for example, file an insurance claim; I've literally never done so.

That said, it's still horrible, and so far as I can tell it's an open invitation for insurance companies to game ObamaCare, and that is new.