§ 27-18-73. Prohibition on annual and lifetime limits.
(a) Annual limits.
(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a
health insurance carrier and a health benefit plan subject to the jurisdiction of
the commissioner under this chapter may establish an annual limit on the dollar amount
of benefits that are essential health benefits provided the restricted annual limit
is not less than the following:
(i) For a plan or policy year beginning after September 22, 2011, but before September
23, 2012 — one million two hundred fifty thousand dollars ($1,250,000); and
(ii) For a plan or policy year beginning after September 22, 2012, but before January 1,
2014 — two million dollars ($2,000,000).
(2) For plan or policy years beginning on or after January 1, 2014, a health insurance
carrier and a health benefit plan shall not establish any annual limit on the dollar
amount of essential health benefits for any individual, except:
(i) A health flexible spending arrangement, as defined in section 106(c)(2) of the federal Internal Revenue Code, a medical savings account, as defined in section 220 of the federal Internal Revenue Code, and a health savings account, as defined in section 223 of the federal Internal Revenue Code, are not subject to the requirements of subsections (a)(1) and (a)(2) of this section.
(ii) The provisions of this subsection (a) shall not prevent a health insurance carrier
and a health benefit plan from placing annual dollar limits for any individual on
specific covered benefits that are not essential health benefits to the extent that
such limits are otherwise permitted under applicable federal law or the laws and regulations
of this state.
(3) In determining whether an individual has received benefits that meet or exceed the
allowable limits, as provided in subsection (a)(1), a health insurance carrier and
a health benefit plan shall take into account only essential health benefits.
(b) Lifetime limits.
(1) A health insurance carrier and health benefit plan offering group or individual health
insurance coverage shall not establish a lifetime limit on the dollar value of essential
health benefits for any individual.
(2) Notwithstanding subsection (b)(1) above, a health insurance carrier and health benefit
plan is not prohibited from placing lifetime dollar limits for any individual on specific
covered benefits that are not essential health benefits, in accordance with federal
laws and regulations.
(c)(1) The provisions of this section relating to lifetime limits apply to any health insurance
carrier providing coverage under an individual or group health plan, including grandfathered
health plans.
(2) The provisions of this section relating to annual limits apply to any health insurance
carrier providing coverage under a group health plan, including grandfathered health
plans, but the prohibition and limits on annual limits do not apply to grandfathered
health plans providing individual health insurance coverage.
(d) This section shall not apply to a plan or to policy years prior to January 1, 2014,
for which the Secretary of the U.S. Department of Health and Human Services issued
a waiver pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4)
Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified
disease indemnity; (8) Sickness or bodily injury or death by accident or both; and
(9) Other limited benefit policies.
(e) [Deleted by P.L. 2024, ch. 201, § 1 and P.L. 2024, ch. 202, § 1.]