Deductible Maximums & Out-of-Pocket Maximums

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The ACA limits cost-sharing within a benefit plan through the:

  • establishment of maximum dollar amounts that insured people in small group and individual plans may pay toward in-network plan deductibles and
  • total costs for claims related to in-network essential benefits.

Deductible maximums

The ACA establishes that the maximum deductible in a non-grandfathered benefit plan be no greater than $2,000 for an individual and $4,000 for a family. This requirement goes into effect with a group’s first effective date on or after Jan. 1, 2014.

The law allows for some leeway to exceed this maximum if it becomes necessary to meet a metal tier.  Additional guidance related to deductible maximums is anticipated as it remains unclear whether this flexibility is available only as necessary to achieve bronze-level plans (60%) or if it may also be used to meet other metal tiers.  Additionally, while the law allows for the use of Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs) to be used, it remains unclear as to whether deductible maximums may be exceeded when balanced by these funding arrangements.

Out-of-pocket maximums

Out-of-pocket costs refer to all payments made by an insured in a given plan year for services covered by a health benefit plan (excluding premium).  The ACA establishes a maximum annual out-of-pocket amount of $6,250 for an individual and $12,500 for a family which may be paid for in-network essential benefits covered under a plan with anticipated increases for inflation.  Once a maximum is reached in a given plan year any additional costs incurred for in-network essential benefits covered by the plan will be covered at 100% for the balance of the plan year.