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.
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.