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New Guidance on 2016 Limits for Annual OOP Max

Oct 05, 2015

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 ($6,850 in 2016). 

Note this guidance does not apply to deductible amounts.  Plans with OOPM greater than $6,850 must be updated because an individual otherwise could face covered expenses over the $6,850 limit. If the plan has network and non-network benefits, then only the network benefits are subject to the rule. 

Affordable Care Act (ACA) Ceiling on OOPM Expenses

2016: $6,850 single/$13,700 family
The ACA OOPM rules apply to all group sizes - fully insured and self-funded (ASO). Exceptions include grandfathered plans and 1-50 Transitional Relief customer groups. 

Internal Revenue Service Ceiling on OOPM Expenses for High-Deductible Health Plans (HDHPs)/Health Savings Accounts (HSAs) - Limits are Less Than ACA Limits

2016: $6,550 single/$13,100 family 
Note: The $6,550 ceiling only applies to single-tier coverage for HSA plans. HSA plans can have a family OOPM at $6,850.

UnitedHealthcare offers three industry accepted solutions for their customers. 

Option 1:  Embed the OOPM (change both deductible and OOPM to embedded). This option is available for all plans except High Deductible Health Plans (HDHPs)/Health Savings Accounts (HSAs) with family deductibles less than $2,600. 

Option 2: Lower the family OOPM to $6,850 or less (lower family OOPM while maintaining non-embedded). This option is available for plans including lower-deductible HSA plans. For high deductible plans, the family deductible may also need to be lowered. 

Option 3:  Non-embedded family deductible and embedded family OOPM
This option is available for all non-standard plans including lower-deductible HSA plans, but is more complex and has some risks. UnitedHealthcare recommends that customers considering Option 3 contact a member of their b&p Sales Team to discuss this option further. 

Action Required by Customers 
Fully Insured/Standard: Small and Large Group customers with standard plans will be updated by UnitedHealthcare to maintain compliance for January  1, 2016 and later plan years. There is no action required for these customers. 

Fully Insured/Non-Standard or Self-Funded: Customers with non-standard/custom plans that use non-embedded OOPM levels greater than $6,850 must modify their plans by selecting Option 1, 2, or 3. 

For more information about OOPM, please ​contact a member of your b&p Sales Team - 888.722.3373.

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