Per Visit Dollar Limits for Essential Health Benefits?
We understand from all the regulations that there is no annual or lifetime dollar limit for essential health benefits. However, there is nothing that indicates a per visit dollar maximum cannot be applied. We have a situation where the ambulance benefit is $300 per trip. It falls under essential health benefits. The reinsurer indicates that the per trip (visit) limit does not fall under that annual/lifetime limit and only the $300 will apply toward the $30,000 air ambulance charge.
An insurer will only pay up to an allowed amount each time you receive a covered service. There is no lifetime or annual limits to the amount they will spend doing that, but it does limit the amount they will spend for each specific service. The remainder not covered by the allowed amount is called balance billing. Balance billing doesn't count toward out-of-pocket maximums or deductibles.
Air ambulance charges are a hard one, those can be really pricey. Not aware of any legislation in the PPACA or otherwise that regulates what portion an insurer must pay specifically, however all plans must cover at least 60% of out-of-pocket costs on covered services on average, so that does factor in.
The above being said, if you got a bill for $29,700 you should appeal immediately to see what can be done about it.
Learn more about your appeal rights.
Definitively, can there be a per visit dollar maximum set on essential benefits as long as there is no lifetime or annual maximum set?
Yes there can. That goes for all services covered under a plan and subject to cost sharing. It’s called an “allowed amount”.
“Allowed amount is the maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing).”
It’s important to note that “balance billing” typically doesn’t count toward cost sharing thresholds like deductibles and out-of-pocket maximums.
Just to be clear, this is not a negotiated rate but specific dollar limit in the employer’s Summary Plan Document that limits ambulance services to $300 per visit. Need to ascertain if this is allowed under ACA.