Out-of-Pocket Maximum

Summary

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 single-tier ACA OOPM ceiling ($7,350 in 2018). High deductible health plans (HDHP)/HSAA  limits are lower than ACA limits ($6,650).

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 and released in the annual Notice of Benefit and Payment Parameters. 

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.

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Maximum OOPM for 2018 Plan Years

Self-only: $7,350

Family:   $14,700

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Maximum OOPM for HDHP/HSA Plans in 2018

Self-only: $6,650

Family:  $13,300

Fully Insured/Standard

Small and large group customers with standard plans will be updated by UnitedHealthcare to maintain compliance for January 1, 2018 and later plan years.