Well this is a load of bullshit, just had someone exceed benefit maximum for prescription coverage..

[Humanist_Activist]

I keep things general to keep things legal(HIPAA and all that).

But I thought, under the ACA, that annual and lifetime benefit caps are no more, that plans have to follow the rules of the ACA here, is there some exception I'm not aware of, or is it possible this is an error?

[unblock]

1. when you say "benefits maximum", what do you mean?

do you mean the plan won't pay for absolutely anything, they're done? that i believe is not permitted.

or do you mean they won't pay for more than a certain quantity or refill frequency for a particular medication? this i believe does happen and is permitted, stupid though it may be. my own plan limits me to 12 zomig nasal sprays per month, and even for that i needed a "prior authorization". if i get a 13th migraine in a month i'll have to go to the e.r. and my insurance company will be out far more than they would be had they just let me get a few extra doses.

[Humanist_Activist]

3. They won't pay for any prescriptions for the rest of the year.

Used to get these messages all the time last year, I was hoping, with the passage of Obamacare, that I wouldn't have to explain to members that their prescriptions are no longer paid for until the first of next year.

[Liberal Veteran]

2. Well, it could depend on the particular drug itself.

I know certain drugs are limited to a certain quantity per period of time and their are probably some caps on drugs like smoking cessation drugs or erectile dysfunction and sometimes fertility drugs.

[Humanist_Activist]

4. I'm keeping things general, but this is NOT a drug you can stop taking, outside of some...

really awesome medical breakthroughs that would make millions of people's lives much easier.

[unblock]

5. looks like there are a few loopholes for the annual limits (though not on the ban on lifetime caps):

http://www.hhs.gov/healthcare/rights/limits/

Some Important Details

Be aware that plans can put an annual dollar limit and a lifetime dollar limit on spending for health care services that are not considered “essential.”

If the new rules apply to your plan, they will affect you as soon as you begin a new plan year or policy year on or after September 23, 2010. (For example, if your policy has a calendar plan year, the new rules would apply to your coverage beginning January 1, 2011).

If you have a “grandfathered” individual health insurance policy, your health plan is not required to follow the new rules on annual limits. (A grandfathered individual health insurance policy is a plan that you bought for yourself or your family; that you did not receive through your employer; and that was issued on or before March 23, 2010.) If you’re not sure whether your plan is grandfathered, ask your insurance company.

The ban on lifetime dollar limits for most covered benefits applies to every health plan — whether you buy coverage for yourself or your family, or you receive coverage through your employer.

Some plans may be eligible for a waiver from the rules concerning annual dollar limits, if complying with the limit would mean a significant decrease in your benefits coverage or a significant increase in your premiums.

[Wella]

8. Were those loopholes part of the ACA or were they created by HHS after the fact?

If they were created by HHS, they can be reversed without Congress and we should fight them.

[unblock]

11. at least some are in the aca --

the non-essential thing is in section 2711(b), for instance.

http://housedocs.house.gov/energycommerce/ppacacon.pdf

the stupid link won't let me copy/paste the text itself.

[Wella]

12. Then it will take an act of Congress--impossible now

The GOP won't do anything to improve ACA; the Senate won't do anything to undermine it. We're stuck.

[etherealtruth]

6. Is it related to the Medicare drug benefit debacle?

I don't think the ACA fixed the mess "W" created (hope to be educated by those more knowledgeable than I)

[jeff47]

7. Most of the ACA regulations cover plans on the exchanges

A whole lot of corporate plans still have some nasty features. Plus, there's the "grandfathered" plans that can still have all the limits.

How the ACA deals with this in the long run is the really bad index on the "Cadillac plan" tax threshold. Assuming corporate premiums keep growing at about the same rate, it's not going to be too long until it's cheaper to pay the "company doesn't offer insurance" penalty instead of offering even a minimum plan.

Which puts people onto the exchanges, and severs the link between work and health insurance. Even better, it does it in a way where the blame falls on a company's greed.

And since the exchanges are now where we need to get public options or single payer, we want to get as many people as we can off their company's insurance and onto the exchange plans.

[Humanist_Activist]

9. I'm suspecting this is close to the truth, it is an employer plan...

Just surprised that I encountered this.

[jazzimov]

13. That explains it -

it's an employer plan, not an ACA.

[elleng]

10. Sorry about this. I just posted this: Beware of Shifting Options Within Medicare Plans.

Open Season is beginning shortly, so you can study and make better decisions for next year IF you have Medicare.

http://www.nytimes.com/2014/10/04/your-money/beware-of-shifting-options-within-medicare-plans.html?action=click&pgtype=Homepage&version=HpHedSumMediumMediaFeature&module=c-column-middle-span-region&region=c-column-middle-span-region&WT.nav=c-column-middle-span-region

[femmocrat]

14. That is an excellent article, BTW.

It explains a lot and has additional links for more details.

[99Forever]

15. Is it actually a ACA eligible plan?

Or is it one of those "you can keep your policy if you like it" exceptions (concessions)?

[Indykatie]

16. HIPAA is Not Issue in Discussion if No Patient Info Involved

and you have not provided enough info to determine if this is BS that ACA should have addressed or something else at play. i.e. type of policy. It's rare to find Rx maximums in Employer plans but it could happen.