Limits on Out­-of-­Pocket Maximums

For plan years beginning on or after January 1, 2014, non-­grandfathered group health plans may not require a participant to pay cost-­sharing (e.g., deductibles, co­-payments, co-­insurance) in excess of the out-of­-pocket maximum that applies to HSA-­compatible high deductible health plans (in 2014, $6,350 for individual coverage or $12,700 for family coverage; in 2015, $6,600 for individual coverage or $13,200 for family coverage). In other words, after a participant has paid the applicable amount of cost­-sharing for the plan year, the plan must pay for all covered benefits at 100% for the remainder of the plan year and may not collect any additional cost-sharing from the participant. 

Note: The limits on cost sharing only apply to certain types of health plans, such as major medical insurance. They do not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident insurance. Click here for more information about the types of benefits that are exempt from the ACA plan design mandates.

Neither American Fidelity Assurance Company nor American Fidelity Administrative Services provides tax or legal advice and, given the complexity of these laws, we always recommend working with your legal counsel on how the laws impact your specific situation.