ACA §2711 (No Lifetime/Annual Limits)
ACA §2711 prohibits lifetime AND annual dollar limits on Essential Health Benefits. Plans that try to enforce a 'visit cap' that functions as a dollar cap, or that re-categorise an essential benefit to dodge the rule, are non-compliant.
What ACA §2711 (No Lifetime/Annual Limits) does
ACA §2711 (42 U.S.C. §300gg-11) prohibits both lifetime dollar limits and annual dollar limits on Essential Health Benefits (EHBs) for non-grandfathered group health plans and individual health insurance. EHBs include ambulatory care, emergency, hospitalization, maternity/newborn, mental health/SUD, prescription drugs, rehabilitative/habilitative services, lab services, preventive/wellness, and pediatric services (incl. oral + vision). Plans may still impose annual VISIT or DAY limits on specific services but cannot dollar-cap the underlying coverage. Annual dollar limits on non-EHB benefits are permitted.
When to invoke it
Cite §2711 when a plan denies based on having reached a lifetime maximum or an annual dollar cap on what is plainly an EHB. Common scenarios: lifetime cap on PT/OT (rehabilitative), annual dollar cap on prescription drugs, lifetime cap on transplant — all illegal for EHB services on non-grandfathered plans.
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Lifetime dollar limit on EHBs | Prohibited |
| Annual dollar limit on EHBs | Prohibited |
| Annual visit/day limit on specific service | Permitted if medically necessary basis exists |
Plans this applies to
- Non-grandfathered group health plans
- Non-grandfathered individual health insurance
- ACA Marketplace plans
Frequently asked questions
What does ACA §2711 (No Lifetime/Annual Limits) require?
ACA §2711 (42 U.S.C. §300gg-11) prohibits both lifetime dollar limits and annual dollar limits on Essential Health Benefits (EHBs) for non-grandfathered group health plans and individual health insurance. EHBs include ambulatory care, emergency, hospitalization, maternity/newborn, mental health/SUD, prescription drugs, rehabilitative/habilitative services, lab services, preventive/wellness, and pediatric services (incl. oral + vision). Plans may still impose annual VISIT or DAY limits on specific services but cannot dollar-cap the underlying coverage. Annual dollar limits on non-EHB benefits are permitted.
When do I cite ACA §2711 (No Lifetime/Annual Limits) in an appeal?
Cite §2711 when a plan denies based on having reached a lifetime maximum or an annual dollar cap on what is plainly an EHB. Common scenarios: lifetime cap on PT/OT (rehabilitative), annual dollar cap on prescription drugs, lifetime cap on transplant — all illegal for EHB services on non-grandfathered plans.
What are the key deadlines under ACA §2711 (No Lifetime/Annual Limits)?
Lifetime dollar limit on EHBs: Prohibited. Annual dollar limit on EHBs: Prohibited. Annual visit/day limit on specific service: Permitted if medically necessary basis exists
Which plans does ACA §2711 (No Lifetime/Annual Limits) apply to?
Non-grandfathered group health plans; Non-grandfathered individual health insurance; ACA Marketplace plans.
Related
- CARC 35Common denial code where ACA §2711 (No Lifetime/Annual Limits) applies.
- CARC 119Common denial code where ACA §2711 (No Lifetime/Annual Limits) applies.
- 42 CFR 422 Subpart MThe Medicare Advantage appeal track. MA enrollees have FIVE levels of appeal (vs the 2 levels typica
- 42 CFR 438 Subpart FThe federal floor for Medicaid managed care appeals. Beneficiaries get internal plan appeal + State
- ACA §1557 (Nondiscrimination)ACA §1557 prohibits discrimination in health programs and activities on the basis of race, color, na
- ACA §2713 (Preventive Services)ACA §2713 requires non-grandfathered plans to cover specified preventive services with ZERO cost-sha
Sources
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