The Affordable Care Act (ACA) provides that a non-grandfathered group health plan must limit an enrollee’s out-of-pocket costs. While there has been clear definition about these maximum limitations for self-only coverage, it was not as clear whether these limits also applied to those in self-funded or group health plans. Are individuals in aggregate plans covered by the limitations, or are they governed by group limits?
For plan or policy years beginning in 2015, the maximum cost-sharing, or out-of-pocket, is $6,600 for self-only coverage and $13,200 for other than self-only coverage. These amounts increase in 2016 to $6,850 and $13,700 respectively.
In its final Health and Human Services (HHS) Notice of Benefit and Payment Parameters, HHS clarified that under the ACA, the self-only maximum annual limitation in 2016 on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only or group coverage.
This clarification will affect all members of group health plans who have “aggregate” family deductibles in 2016. Let’s say one family member has claims that result in $10,000 of cost sharing. Under the new clarifications, the self-only maximum annual limitation of $6,850 kicks in first. Therefore, the amount that goes toward the family deductible is $6,850. The plan bears the difference of $3,150.
The clarification also includes high-deductible health plans (HDHP).
We Can Help
Marsh & McLennan Agency formerly Benefits Resource Group can educate employers about their group health plan parameters and help determine if this ruling affects them.
Are you interested in learning more about group plans at your company? Marsh & McLennan Agency formerly Benefits Resource Group will help ensure your health care dollars are spent productively.
We encourage you to contact Ross W. Farro. Ross is a Principal with Marsh & McLennan Agency formerly Benefits Resource Group and specializes in assisting clients with ACA implementation and group health insurance needs. You can contact Ross by phone at 216-393-1820 or by email at firstname.lastname@example.org.