Limits on Out-of-Pocket Maximums
For plan years beginning on or after January 1, 2014, non-grandfathered plans may not require a participant to pay cost-sharing (e.g., deductibles, co-pays, co-insurance) in excess of the out-of-pocket maximum that applies to HSA-compatible high deductible health plans (in 2012, $6,050 for individual coverage or $12,100 for family coverage). In other words, after a participant has paid the applicable amount of cost-sharing for the plan year, the plan must pay for all covered benefits at 100% for the remainder of the plan year and may not collect any additional cost-sharing from the participant.
Note: The limits on cost sharing only apply to certain types of health plans, such as major medical insurance. They do not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident insurance. Click here for more information about the types of benefits that are exempt from the Health Care Reform plan design mandates.
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Limits on Out-of-Pocket Maximums FAQs
- Will higher out-of-pocket maximums be available for group plans offered through the state Health Insurance Exchanges?
Answer: No, group plans offered through the Exchanges will also have to comply with requirement to impose out-of-pocket maximums.
- May an employee purchase an individual insurance policy with a higher cost-sharing limit?
Answer: Yes. The out-of-pocket maximum does not limit the cost-sharing an insurer may require on an individual health insurance policy.
American Fidelity Assurance Company does not provide tax or legal advice.
ESB-839(0111)
