Non-grandfathered health plans are required under The Affordable Care Act (ACA) to limit an enrollee’s out-of-pocket costs for essential health benefits each year. This annual limit is often referred to as the “out-of-pocket (OOP) maximum.”
Recent guidance will require the self-only OOP maximum to be embedded family coverage when the plan’s OOP maximum for family coverage exceeds the ACA’s limits for individual coverage. This requirement will take effect beginning with the 2016 plan year, when the OOP maximum for self-only coverage will be $6,850.
This guidance applies to all non-grandfathered group health plans, including self-funded plans and insured plans of all sizes.
High Deductible Health Plans
While this change will have a significant impact on many employer-sponsored health care plans, high deductible health plans are likely to be affected the most. This is due to the fact that high-deductible family plans have higher cost-sharing limits. They are also typically designed to administer a single OOP limit on all family coverage with no underlying OOP maximum for each individual enrolled in the family plan.
Under the new guidance, many high-deductible family health plans will need to be modified so that a single individual’s OOP costs do not exceed the specified maximum. For instance, currently, a plan could have an $8,000 OOP limit for family coverage and require that limit to be satisfied before it covers expenses at 100 percent, even if one individual incurs all of the expenses.
According to the guidance, this type of plan design will no longer be permitted for non-grandfathered plans, and the plan would have to be amended so that each individual would not be required to pay more than the OOP maximum for individual coverage for essential health benefits.