The ACA requires that the out-of-pocket maximum be updated annually, based on the percent increase in average premiums per person for health insurance coverage.
• For 2015, the out-of-pocket maximum is $6,600 for self-only coverage and $13,200 for family coverage.
• Under the final rule, the out-of-pocket maximum increased for 2016 to $6,850 for self-only coverage and $13,700 for family coverage.
HHS also clarified in the final rule that the out-of-pocket maximum applies for the plan year, and not the calendar year, for non-calendar year plans. Also, plans and issuers may, but are not required to, count out-of-network cost-sharing against the annual out-of-pocket maximum.
Finally, HHS clarified in the final rule that the annual limitation on cost-sharing for self-only coverage applies to all individuals, regardless of whether the individual is covered by a self-only plan or family coverage. In both of these cases, an individual’s cost sharing for essential health benefits may never exceed the self-only annual limitation on cost-sharing.
For example, if a family plan has an annual limitation on cost-sharing of $10,000, and one individual in the family plan incurs $20,000 in expenses from a hospital stay, that particular individual would only be responsible for paying the cost-sharing related to the costs of the hospital stay covered as essential health benefits, up to the annual limit on cost-sharing for self-only coverage (assuming an annual limitation of $6,850 for 2016, the maximum for that year).
• The reinsurance program’s annual contribution rate for 2016.
• The 2016 open enrollment period.
• The 2016 annual limitations on cost-sharing.