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 generalA group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—(2) Annual limits prior to 2014With 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 limitsSubsection (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.
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?