Obamacare Facts #1-#3


1) LIFETIME LIMITS PROHIBITED BUT… - Although the Affordable Care Act (ACA) prohibits “lifetime limits on the dollar value of benefits for any participant or beneficiary,” it does not prohibit limits on patient access to care. It only prohibits limits on the “dollar value of benefits,” a value that can change over time and according to who sets the value. Additionally, many people change health insurance over their lifetime, so the value of such a prohibition may mean little to most people, but it provided the Obama administration with a talking point they could use to sell the law. (Sec. 1001 of the ACA, which amends Sec 2711 of title XXVII of the Public Health Service Act)


2) ANNUAL AND LIFETIME LIMITS ALLOWED – Despite Obamacare Fact #1, this section of the ACA says the former section’s prohibition on lifetime limits “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” as defined by the ACA. Thus, if the Secretary of HHS, who controls what’s in the essential health benefits (EHB) list, decides to limit services and not include the services you need in a future EHB list, insurers are allowed to establish annual and lifetime limits on any services not on the EHB list. (Sec. 1001 of the ACA, which amends Sec 2711 of title XXVII of the Public Health Service Act)


3) COVERAGE RESCINDED FOR “FRAUD” – The ACA says once an individual is covered, the insurer cannot take away that person’s plan, unless the covered individual “has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage.” Imagine the fun a health plan’s attorney could have with these words once you get a serious illness. How closely have you read the terms of your plan? Did you report every single instance of illness and injury for you and the rest of your family? (Sec. 1001 of the ACA, which amends Sec 2712 of title XXVII of the Public Health Service Act)