Essential Benefits and Health Reform
Limits on Essential Benefits continued...
Your state sets a benchmark plan. For now, each state decides which services, tests, and tools all of its private plans must cover. To do this, each state chooses a typical employer plan to use as a model, called the benchmark plan.
If the benchmark plan covers in vitro fertilization or autism treatment, for instance, your plan will, too. If the benchmark plan doesn't cover these, your plan may still cover them, but it doesn't have to.
Check out your state's benchmark plan at the federal government's CCIIO web site.
Your health plan can limit visits. Your insurer may only pay for a certain number of visits on some types of care, like physical therapy, for example. Check the fine print in your plan's summary of benefits.
Your health plan cannot cap the cost of care. Each year and over your lifetime, your plan cannot put a dollar limit on covered essential health benefits. So if you have a serious or chronic illness, once you reach your plan’s out-of pocket maximum, your insurer will pay the full cost of care provided by in-network providers.