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GAO-11-725R 1 (2011-06-14)

handle is hein.gao/gaobaanym0001 and id is 1 raw text is: i ~G A 0 Accountability I ntegity * Reliability United States Government Accountability Office Washington, DC 20548 June 14, 2011 Congressional Committees Subject: Private Health Insurance: Waivers of Restrictions on Annual Limits on Health Benefits The Patient Protection and Affordable Care Act (PPACA), which became law in March, 2010, generally prohibits health insurance issuers and group health plan sponsors from imposing annual limits on the dollar value of essential covered health benefits beginning on January 1, 2014, but allows restricted annual limits, as defined by the Secretary of Health and Human Services (HHS), on the value of those benefits until that time.'2 In setting these annual limits, HHS is statutorily required to ensure that individuals' access to needed services remains available with a minimal impact on plan premiums. In June 2010, HHS set restrictions on annual limits for each plan year from September 2010 through December 2013. To mitigate a potential impact on individuals' access or premiums for existing plans with benefit limits below these amounts, HHS established a waiver program based on the statutory requirement. Under the program, issuers or other group health plan sponsors could apply for a waiver from the annual limits set by HHS if they attested and presented evidence that meeting the annual limits would result in diminished access to benefits or a significant increase in premiums. To implement various provisions of PPACA, including those related to annual limits, HHS created what is now called the Center for Consumer Information and 'Effective for plan or policy years beginning on or after September 23, 2010, PPACA also prohibits lifetime limits on the dollar value of essential health benefits. Pub. L. No. 111-148, § 1001, 10101(a), 124 Stat. 119, 130, 883 (adding and amending various sections to part A of title XXVII of the Public Health Service Act (PHSA)) (codified at 42 U.S.C. §§ 300gg-11 et seq.) (requirements for benefit limits imposed by § 2711 of the PHSA, codified at 42 U.S.C. § 300gg-11). 2Health plan coverage may be offered by health insurance issuers, such as a health insurance company or health maintenance organization (HMO), or by sponsors of group health plans, such as employers, unions, or trade associations. Pursuant to § 1302(b) of PPACA, essential health benefits include (1) ambulatory patient services, (2) emergency service, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. Pub. L. No. 111-148, § 1302, 124 Stat. 163. For nonessential health benefits, annual or lifetime limits may be imposed to the extent that such limits are otherwise permitted under federal or state law. 375 Fed. Reg. 37188, 37236 (June 28, 2010) (to be codified at C.F.R. § 147.126(d)(1)). The minimum annual limit for plan years beginning on or after Sept. 23, 2010, but before Sept. 23, 2011, was $750,000. The minimum annual limit for plan years beginning on or after Sept. 23, 2011, but before Sept. 23, 2012, will be $1.25 million. The minimum annual limit for plan years beginning on or after Sept. 23, 2012, but before Jan. 1, 2014, will be $2 million. GAO-11-725R Health Benefit Limit Waivers

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