COST SHARING

Cost Sharing

The Affordable Care Act establishes annual limits on in-network out-of-pocket maximums on Essential Health Benefits (EHBs) for nongrandfathered plans. (This cost-sharing provision does not apply to grandfathered plans.) The annual out-of-pocket maximum applies to the plan on the first day of the first plan year. The in-network annual out-of-pocket maximum may be divided across multiple categories of benefits, provided the aggregate of all separate out-of-pocket maximums applicable to all in-network EHBs under the plan do not exceed the annual out-of-pocket maximums for that plan year.


Remember!

Self-funded group health plans are not required to cover Essential Health Benefits. But, if they do, they cannot impose lifetime or annual dollar limits on those benefits.

2019

A group health plan’s in-network out-of-pocket maximum for EHBs for the 2019 plan year cannot exceed $7,900 for self-only coverage and $15,800 for other-than-single coverage, an increase of 7 percent from 2018. The in-network out-of-pocket maximum applies to all individuals, regardless of whether an individual has a self-only plan or other-than-single coverage (including a high deductible health plan).

2018

A group health plan’s annual in-network out-of-pocket maximum for EHBs for the 2018 plan year cannot exceed $7,350 for a self-only plan and $14,700 for other than single coverage. The in-network individual out-of-pocket maximum applies to all individuals, regardless of whether an individual has a self-only plan or other than single coverage (including a high-deductible health plan). The 2018 cost-sharing limits represent a 2.8 percent increase from 2017 cost-sharing limits.

2017

A group health plans’ annual in-network out-of-pocket maximum for EHBs for the 2017 plan year cannot exceed $7,150 for self-only coverage and $14,300 for other than single coverage. The in-network individual out-of-pocket maximum applies to all individuals, regardless of whether the individual has a self-only plan or other than single coverage (including a high-deductible plan).

2016

A group health plan’s annual in-network out-of-pocket maximum for EHBs for the 2016 plan year cannot exceed $6,850 for self-only coverage and $13,700 for all other coverage. The final regulation also clarifies that the in-network individual out-of-pocket maximum applies to all individuals, regardless of whether the individual has a self-only plan or other than single coverage (including a high-deductible health plan).

For example, if an individual with family coverage enrolled in a high-deductible health plan has out-of-pocket costs of more than $6,850 in 2016, the individual will only be responsible for out-of-pocket costs of $6,850, even if the family deductible is higher.

2015

Effective in 2015, all member in-network cost-sharing, such as copayments, coinsurance and deductibles, apply to the annual out-of-pocket maximum. For plan years on or after Jan. 1, 2015, the in-network OOP maximum cannot exceed $6,600 for a self-only plan and $13,200 for other than single coverage.

2014

Medical out-of-pocket maximums: In-network out-of-pocket maximums in 2014 could not exceed the following limits: $6,350 for a self-only plan, $12,700 for other than single coverage. In addition, all member in-network cost-sharing, such as copayments, coinsurance and deductibles, applied to the annual out-of-pocket maximum.

Maximums for a plan that used more than one service provider to administer benefits: For the first plan that began on or after Jan. 1, 2014, when a group health plan used more than one service provider to administer benefits that were subject to the annual limitation on out-of-pocket maximums, federal agencies considered the annual limitation on out-of-pocket maximums to be satisfied if both of the following conditions were satisfied:

  • The plan complied with the out-of-pocket maximum requirements for major medical coverage (excluding, for example, prescription drug coverage and pediatric dental coverage); and
  • To the extent that the plan included an out-of-pocket maximum on coverage that did not consist solely of major medical coverage (for example, if a separate out-of-pocket maximum applied with respect to prescription drug coverage), such out-of-pocket maximum should not have exceeded the dollar amounts listed above ($6,350 for a self-only plan, $12,700 for other than single coverage for 2014).

There were two ways in 2014 to interpret the provision regarding more than one benefit administrator:

  • A conservative interpretation would have required that an out-of-pocket maximum be added to the carved-out benefit. (For example, a similar out-of-pocket maximum could have been added to a pharmacy plan administered by a pharmacy benefit manager.)
  • A less conservative interpretation would have been that an out-of-pocket maximum would only apply to the separately administered benefits if the plan already had an out-of-pocket maximum for the benefit.