More Guidance on Cost Sharing

The U.S. Departments of Health and Human Services, Labor and the Treasury reaffirmed that a group health plan’s annual in-network out-of-pocket maximum for Essential Health Benefits^* cannot exceed $6,850 for self-only coverage and $13,700 for all other coverage. The final regulation also clarifies that the in-network individual out-of-pocket maximum applies to all individuals, regardless of whether the individual is covered by a self-only or family plan (including a high-deductible health plan).

This requirement is applicable for plan and policy years that begin on or after 2016. As a result, family coverage offered to an insured large group or self-funded group in 2016 must have maximum out-of-pocket limits on Essential Health Benefits that do not exceed $6,850 for each individual (the approved maximum out-of-pocket limits for self-only coverage) and $13,700 for the entire family (the approved maximum out-of-pocket limits for family coverage).

Previously, the Centers for Medicare and Medicaid Services had indicated this requirement would apply to the individual and small group insurance market, but it was not clear from its announcement if the restrictions also applied to the large group market and to self-funded group health plans. A new document clarifies that the restrictions apply to all non-grandfathered policies and plans beginning on or after 2016.

The departments issued the guidance in “FAQs About Affordable Care Act Implementation (Part XXVII)”