Providence to remove limits on essential health benefits

Among the new rules under federal health care reform legislation is a provision requiring the phasing out of annual and lifetime limits on essential health benefits beginning October 2010, to be completed by Jan. 1, 2014.

Details regarding which benefits will change and how these changes will affect specific plans can be found below. Additional information about this provision can be found at healthcare.gov.

What limits are being removed?

As a result of the guidance provided by federal and state regulators, Providence Health Plan will remove the following limits on essential health benefits:

Essential health benefit Limit removed Product/plan affected
Transplant $250,000 lifetime max OR Commercial Group, Individual
Transplant $350,000 lifetime max WA Commercial Group
Tobacco use cessation $500 lifetime max OR Commercial Group, Individual, Portability
Smoking deterrent medications $500 lifetime max OR and WA Commercial Group (Value Based Open Option only)
Periodic exam/well-baby care $250 per calendar year OR and WA Commercial Group (HSA plans only), Individual
Emergency transportation $1,000 per calendar year WA Small Commercial Group
Chemical dependency $15,000 every two years WA Small Commercial Group
Work related injury/illness $50,000 lifetime max WA Small Commercial Group
Mental health $2,000 per calendar year
replaced with TBD day/visit limit
Individual
Alcohol dependency $4,500 every two years;
replaced with TBD day/visit limit
Individual

Will Providence Health Plan be retaining some limits?

Yes. Following is a list of some of the limits that will continue to appear on our plans:

Not defined as an
"essential health benefit"
Limit retained Product/plan affected
Temporomandibular joint $1,000 per calendar year; $5,000 lifetime max OR and WA Commercial Group
Mental health/chemical dependency Residential services: 60 days per calendar year (only until 8/1/2011 OR filing and 1/1/2012 WA filing) OR and WA Commercial Group, Portability
Skilled nursing facility stay 60 days per calendar year OR and WA Commercial Group, Portability, Individual
Durable medical equipment Removable custom shoe orthotics: $200 per calendar year OR and WA Commercial Group, Individual, Portability
Transplant transportation/lodging $5,000 lifetime max OR and WA Commercial Group, Individual, Portability
Durable medical equipment $2,500 per calendar year Individual only
Office visits to alternative care providers $500 per calendar year OR Commercial Group(HSA plans only)
Emergency transportation $2,000 per calendar year Individual only
Hearing aid $4,000 every four years OR Commercial Group, Individual, Portability
Short-term outpatient rehabilitation (physical, occupational and speech therapy) 30 days per calendar year OR and WA Commercial Group, OR Individual

Which plans are affected by this provision?

  • Providence Health Plan individual and family plans
  • Providence Health Plan commercial fully insured plans
  • Providence Health Plan Oregon portability and Washington conversion plans
  • Providence Health Plan custom and ASO plans

Will grandfathered plans keep their limits on essential health benefits?

No. Group plans will not be allowed to grandfather limits on essential health benefits. Limits must be removed from grandfathered plans.

When will this change be effective?

The removal of limits on essential health benefits goes into effect upon renewal or sale of a new group on or after Oct. 1, 2010.

Why did the federal government create a limits provision?

The removal of limits on essential health benefits is an effort to protect the consumer. Government research found that some people were unable to receive or afford health care after they reached certain limits.

For more information about why the government created this provision, go to www.healthcare.gov.

Can there be copays on essential health benefits?

Yes, copayments are permitted.