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Individual OOP Maximum Will Apply to All Non-GF Plans in 2016

Aug 05, 2015

On May 26, the Departments of Health and Human Services (HHS), Labor (DOL) and Treasury issued ​FAQs clarifying out-of-pocket (OOP) cost-sharing limits within family coverage, which are required as part of the Affordable Care Act (ACA). Specifically, the in-network individual OOP maximum will apply to each individual enrolled in family coverage. The FAQs confirm that the limits will apply to all non-grandfathered plans for plans years beginning on or after January 1, 2016, including:

Small and Small Group insured plans

Large and Small Group self-funded plans

Plans offered on public exchanges

For 2016 plan years, the in-network OOP maximum cost share cannot exceed $6,850 for self-only coverage and $13,700 for family coverage. This means that once a person covered under a family plan reaches his or her individual OOP maximum, all covered expenses for that individual must be paid at 100% plan coinsurance, even when the family OOP maximum may not have been satisfied. Once the family OOP maximum is reached, the plan must pay 100% of all covered expenses regardless of whether each person covered has reached the individual OOP maximum.

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