Volume 39 | Issue 155
Download this For Your Information as a printable PDF
The Department of Health & Human Services has finalized the 2018 out-of-pocket maximums at $7,350 for self-only coverage and $14,700 for other than self-only coverage.
Background
Each year, the Department of Health & Human Services (HHS) releases the HHS Notice of Benefit and Payment Parameters that provides important guidance related to the Affordable Care Act (ACA) marketplaces and various ACA provisions. Earlier this year, HHS released the proposed rule for 2018. (See our September 8, 2016 For Your Information.) On December 16, HHS released the final rule and a Fact Sheet summarizing the guidance. While primarily focused on the ACA marketplaces and insurers offering products in the marketplaces, the rule finalizes the 2018 ACA out-of-pocket maximums that affect large employer and self-insured group health plans.
Out-of-Pocket Maximums
Effective for plan years beginning on or after January 1, 2014, the ACA imposes annual out-of-pocket (OOP) maximums on the amount that an enrollee in a non-grandfathered health plan, including self-insured and large group health plans, must pay for essential health benefits (EHB) through cost-sharing. (See our March 11, 2014 For Your Information.)
In 2017, the OOP limits will be $7,150 for self-only coverage and $14,300 for other than self-only coverage. HHS has finalized the 2018 OOP maximums of $7,350 for self-only coverage and $14,700 for other than self-only coverage.
Will the OOP limits be repealed in 2017?
Probably not. While it is anticipated that Congress will pass, and President-elect Trump will sign, legislation to repeal certain provisions of the ACA starting as soon as 2017, it is unlikely that the ACA OOP limits will be one of those provisions. The reconciliation process that Congress is planning to use for ACA repeal can only be used to repeal ACA provisions that have a direct budgetary impact. The OOP limits likely do not meet that requirement.
ACA Indexed Dollar Amounts
The table below summarizes the ACA indexed dollars limits for 2018 and prior years.
| ACA Indexed Dollar Amounts | ||||||||
| Out-of-Pocket Maximums (1,5) | PCORI Fee (2,5) |
Transitional Reinsurance Fee (6) | Health FSA Salary Reduction Cap (3,5) | Employer Shared Responsibility Annual Assessments (1,4,6,7,8) | ||||
| Self-Only | Other Than Self-Only | 4980H(a) – Failure to Offer Coverage | 4980H(b) – Failure to Offer Affordable, Minimum Value Coverage | Affordability Threshold Under 4980H(b) | ||||
| 2018 | $7,350 | $14,700 | Not available | N/A | Not available | $2,320 (Est.) | $3,480 (Est.) | Not available |
| 2017 | $7,150 | $14,300 | Not available | N/A | $2,600 | $2,260 (Est.) | $3,390 (Est.) | 9.69% |
| 2016 | $6,850 | $13,700 | $2.26 | $27 | $2,550 | $2,160 | $3,240 | 9.66% |
| 2015 | $6,600 | $13,200 | $2.17 | $44 | $2,550 | $2,080 | $3,120 | 9.56% |
| 2014 | $6,350 | $12,700 | $2.08 | $63 | $2,500 | $2,000 | $3,000 | 9.50% |
| 2013 | N/A | N/A | $2.00 | N/A | $2,500 | N/A | N/A | N/A |
| 2012 | N/A | N/A | $1.00 | N/A | N/A | N/A | N/A | N/A |
Notes:
- Indexed to increase in average per capita premium for US health insurance coverage in prior calendar year. Out-of-pocket maximum does not apply to grandfathered plans or retiree-only plans
- Indexed to increases in national health expenditures
- Indexed for CPI-U
- One-twelfth of annual amount assessed on monthly basis. No assessments for 2014
- Applicable dollar amount affected by when plan year ends
- Applies on a calendar year basis
- 2017 and 2018 assessment amounts have not been released. Estimate based on increase in average per capita premium for US health insurance coverage as determined by HHS
- Affordability threshold adjusted consistent with 36B(b)(3)(A)(i)
N/A – Not applicable