Out-of-pocket maximum


Recent guidance from the Department of Health and Human Services (HHS), Department of the Treasury (IRS) and the Department of Labor (DOL) clarified that effective for January 1, 2016 and later plan years, no individual, even when in a family coverage tier, can face an OOPM exposure more than the statutory ACA OOPM.

The Affordable Care Act (ACA) introduced a maximum limit on the amount of cost sharing (out-of-pocket amounts) that can be imposed on a member during a plan year for essential health benefits.  This amount of the out-of-pocket maximum (“OOPM”) is adjusted annually by HHS. 

The annual OOPM requirement applies to all non-grandfathered group health plans, including HDHP plans, regardless of whether the plan is fully insured or ASO. However, it does not apply to transitional relief and retiree only plans.

The OOPM includes copayments, deductibles and coinsurance amounts.

Network plans may, but are not required to, apply cost sharing amounts for out-of-network services towards the annual OOP.

Maximum OOPM for 2025 plan years

Self-only: $9,200

Family:   $18,400

Maximum OOPM for 2024 plan years

Self-only: $9,450

Family: $18,900

Fully insured/standard

Small and large group customers with standard plans will be updated by UnitedHealthcare to maintain compliance.