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How often can an individual covered under each of the Bronze, Silver, Gold, and Platinum tier plans claim coverage benefits, and what are the coverage limits?

closed as unclear what you're asking by ChrisInEdmonton, Victor, Daniel Anderson, Dheer, Nathan L Sep 28 '16 at 16:02

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  • Have you done any research on your own into this? – BobbyScon Sep 27 '16 at 18:22
  • Yes but no proper information I got so far – user10415 Sep 27 '16 at 18:44
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    Didn't I just see and answer virtually identical question on another piece of StackOverflow?? – Loren Pechtel Sep 27 '16 at 20:53
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How frequently you can receive certain services will depend on the specific service. Some services are considered preventive and are mandated by law, these benefits will have certain age and frequency restrictions in order for the service to be considered and paid for as preventive, that should be pretty similar across different plans. Generally frequency of service is based on medical necessity. You can have a single preventive colonoscopy each year if you are a man over a certain age. But if your doctor says you need another one, you can have another one as long as it is medically necessary.

If your plan has something a little less common like chiropractic benefits, there is probably an annual service limit. This just means the carrier will only pay for X number of visits per year. A visit limitation is also pretty common on physical therapy benefits.

As per the ACA, there is no maximum benefit amount. If you get cancer and it costs $1,000,000 in a year, that's fine under any metal-tier plan. How much of the $1,000,000 you're responsible to pay will vary based on your particular plan.

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You can claim as often as you like. The "Metal" tiers just identify how much of the costs you pay versus how much the insurance company will pay (after any deductible).

Plan Category     The insurance company pays    You pay
Bronze                    60%                     40%
Silver                    70%                     30%
Gold                      80%                     20%
Platinum                  90%                     10%

The tier you choose will also affect how much your premiums cost and what your deductible is.

Coverage limits will depend on the individual plan.

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    >"An insurance company could refuse to renew your coverage after a year", no they can't. – quid Sep 27 '16 at 20:54
  • As you said above it is crystal clear but How often I mean can the individual can claim the benefit any number of times in a year or is there any limit? thanks – user10415 Sep 27 '16 at 20:56
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    I don't think your last sentence is correct. – TTT Sep 27 '16 at 21:02
  • Removed the paragraph. – mkennedy Sep 27 '16 at 21:22
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Thanks for all who helped me out with this question.......! Atlast I got the answer to the question about the Annual Limit, Life Limits.

The Affordable Care Act prohibits health plans from putting annual or lifetime dollar limits on most benefits you receive.

Lifetime Limits Thanks to the Affordable Care Act, lifetime limits on most benefits are prohibited in any health plan or insurance policy. Previously, many plans set a lifetime limit — a dollar limit on what they would spend for your covered benefits during the entire time you were enrolled in that plan. You were required to pay the cost of all care exceeding those limits.

Annual Limits The Affordable Care Act bans annual dollar limits that all job-related plans and individual health insurance plans can put on most covered health benefits. Before the health care law, many health plans set an annual limit — a dollar limit on their yearly spending for your covered benefits. You were required to pay the cost of all care exceeding those limits.

The year in 2010 the Annual Limits is $750000 2011 the Annual Limits is $1.2Million 2014 the Annual Limits is $2.0Million

But with the new OBAMA CARE ACT all the limits are prohibhited and there are ten 10 essential benefits for all the Heath Insurance Plans

1.Ambulatory patient services (outpatient care you get without being admitted to a hospital) 2.Emergency services 3.Hospitalization (like surgery and overnight stays) 4.Pregnancy, maternity, and newborn care (both before and after birth) 5.Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy) 6.Prescription drugs 7.Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills) 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

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