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ACA Deductible & Out-of-Pocket Requirements

Posted on March 5th, 2013

The U.S. Department of Health and Human Services (HHS) posted final regulations about the deductible and out-of-pocket limitations to the Federal Registrar on February 25, 2013. Section 1302(c) of the Affordable Care Act (ACA) specifies that the maximum deductible for a qualified insurance plan cannot exceed $2,000 for single coverage and $4,000 for family coverage. It also indicates that maximum out-of-pockets cannot exceed that of a HSA-qualified plan.

The maximum out-of-pocket for a HSA-qualified plan in 2013 is $6,250 for single coverage and $12,500 for family coverage. The deductible and out-of-pocket limitations are subject to annual inflationary adjustments.

The final regulations provide clarification that the deductible limitations only apply to non-grandfathered small group health plans. These would be plans offered by employers in most states that have fewer than 50 full-time equivalent employees.

The guidance also suggests that issuers of coverage in the small group market may exceed the annual deductible limit if it would be necessary to achieve a qualification as a bronze, silver, gold or platinum plan. These "metallic" plans must provide coverage that meet minimum actuarial value (AV) requirements. AV is defined as the percentage of health care expenses a plan would cover on average for the standard population and will range between 60-90% based on the coverage tier.

Future guidance for large employer plans (50+ full-time equivalent employees) and self-funded plans is expected, but the current guidance suggests the intention is that the deductible limitations wouldn't apply to these plans. However, the guidance does indicate that the out-of-pocket limitations will apply to all non-grandfathered group health plans including small group plans, large group plans and self-funded plans, as well as individual health plans.

The maximum out-of-pocket limitations include deductible, coinsurance and copay expenses. These new requirements apply to the first plan year that begins on or after January 1, 2014.

The U.S. Department of Labor has published a Frequently Asked Questions (FAQs) document about the new guidance. View FAQs regarding ACA implementation >>

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

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