an individual has met the plan’s OOP max, the plan must pay 100% of covered
benefits. This requirement applied for plan years starting on or after January
1, 2014, except with respect to grandfathered plans.
Department of Health and Human Services has issued regulations in the context
of Exchange-qualified health plans, but these regulations do not apply directly
to other group health plans, such as Employee Retirement Income Security Act (ERISA)
plans (although can be viewed as analogous guidance). The agencies have not
issued regulations applicable to group health plans, but have issued several
Q&As. The most recent Q&As were issued in January and May of this year
and can be found at www.dol.gov/ebsa/faqs
(see Parts XVIII & XIX).
we answer several questions group health plans may have that have been
addressed in the agency Q&As.
What is the OOP Max
the 2014 plan year, the allowed OOP Max amount is $6,350 self / $12,700 family.
the 2015 plan year, the allowed OOP Max amount is $6,600 self / $13,200
What expenses count
toward the OOP max?
ACA provides that cost-sharing amounts that must be counted toward the OOP max
include deductibles, co-insurance, and copayments. The statute provides that
such cost-sharing does not have to include premiums, balance billing amounts
for non-network providers, or spending for noncovered services.
Q&As further clarify that:
are not required to count cost-sharing with respect to non-network providers
toward the OOP max.
are not required to count cost-sharing for noncovered services toward the OOP
are not required to count amounts charged above the usual, customary and
reasonable (UCR) amount toward the OOP max.
only are required to count cost-sharing for essential health benefits toward
the OOP max (the same group of benefits to which the annual and lifetime limit
Plans can limit the costs of prescription drugs
that are counted toward the OOP max to generic only and are not required to
count the cost of brand prescription drugs if a generic is available and
medically appropriate. Note that the determination as to whether a generic
drug is “medically appropriate” is to be made by the individual's personal