On January 9, 2014 the HHS and DOL issued a new FAQ that addressed issues outstanding under PPACA. Here is the update for out-of-pocket maximums:
Out-of-Pocket Limits
The FAQ clarifies that, for non-grandfathered plans, the out-of-pocket maximum:
- Must include deductibles, coinsurance and copayments for essential health benefits (EHBs). A plan may exclude benefits that are not EHBs from the out-of-pocket maximum if it wishes.
- Need not include premiums, costs for non-covered services, or costs for out-of-network services, although it may if it wishes.
- May be separated into different out-of-pocket maximums for different categories of services, but the total of all the separate out-of-pocket maximums cannot exceed the out-of-pocket maximum allowed by the Patient Protection and Affordable Care Act (PPACA), which is $6,350 for self-only coverage or $12,700 for family coverage for 2014.
*This option may be helpful for plans with multiple vendors.
*This technique may not be used to create a separate out-of-pocket maximum for mental health services because that would violate the Mental Health Parity Act (MHPA).
The FAQ also verifies that, to the extent a large group insured plan or a self-funded plan must consider EHBs, it may use any state’s EHB benchmark plan. (Large group insured plans and self-funded plans do not have to offer coverage for the 10 EHBs, but they cannot impose lifetime or annual dollar limits on EHBs.)
If you would like the Frequently Asked Questions – Part XVIII White Paper on all of the new clarifications, please Contact Us!!
