United Benefit Advisors Insight and Analysis Blog

New Out-of-Pocket Maximum Rules Explained

By Bill Olson, Senior VP, Operations at United Benefit Advisors
  Apr 1, 2014 11:29:00 AM

PPACAQ: I know there are new out-of-pocket maximum rules beginning in 2014. Can you explain them?

A: Beginning with the 2014 plan year, plans may not have an out-of-pocket maximum greater than $6,350 for single coverage and $12,700 for family coverage. The out-of-pocket maximum must include copays (which is a change for many plans), coinsurance and deductible. It does not include premiums. The out-of-pocket maximum only needs to apply to in-network essential health benefits for covered services.

To help plans adjust to the new requirements, there are two limited exceptions:

  • For 2014 only, a plan that has different providers (such as one provider for major medical and another provider for prescription drug benefits) may simply apply the out-of-pocket maximum to the major medical benefit. If the separate (often prescription drug) benefit has an out-of-pocket maximum, it cannot exceed $6,350 for single coverage and $12,700 for family coverage.
  • For years after 2014, a plan that has different providers may divide the out-of-pocket maximum among the benefits provided by the different providers, as long as the total does not exceed the maximum.

Example: In 2015, the out-of-pocket maximum is expected to be $6,750 for single coverage and $13,500 for family coverage. An employer could use, for instance, a $5,000 deductible for single and a $10,000 deductible for family major medical coverage and a $1,750 deductible for single and a $3,500 deductible for family prescription drug coverage.

PPACA does not override mental health parity requirements, so separate out-of-pocket maximums may not be used for mental health coverage. This requirement does not apply to grandfathered plans.  It also does not apply to renewed 2013 policies if the state permits renewal of policies that do not fully comply with PPACA.

For more information on out of pocket, minimum essential coverage and minimum value rules, request UBA's resource, IRS Issues Final Regulations on Employer Shared Responsibility.

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