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ACA Out-of-Pocket Max Clarity

Posted on August 20th, 2013

The Affordable Care Act (ACA) requires non-grandfathered plans to impose limitations on out-of-pocket expenses for essential health benefits starting in 2014. The out-of-pocket limitations will be capped next year at $6,350 for single coverage and $12,700 for family coverage. 

However, some self-funded plans will be exempt from this requirement until 2015. The guidance indicates that self-funded plans contracting with multiple service providers can delay this requirement for one year. 

For example, some self-funded plans contract with one service provider to administer their major medical benefits and another service provider to administer their pharmacy benefits.

The reason for the delay has been linked to administrative complications in tracking the out-of-pocket expenses when multiple service providers are used.   

The new out-of-pocket limitations will still apply in 2014 to all individual health plans, fully insured group health plans and self-funded group health plans that use a single service provider to administer their plan benefits.

Click here to view the guidance >>

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Note: The materials contained within are provided for informational purposes only and do not constitute legal or tax advice.