Credit portal




Out-of-Pocket Maximum

what is out of pocket maximum health insurance


Beginning in 2014, all in-network member cost sharing, including flat-dollar copayments, must accumulate to a plan's Out-of-Pocket Maximum (OOPM). This change applies to both fully insured (small and large group) and self-funded plans. Grandfathered plans are exempt from the OOPM rules.

The OOPM limit for a non-HSA (health savings account) plan for the plan year starting on or after Jan. 1, 2014, is equal to the 2014 OOPM for an HSA plan, which is $6,350 for single coverage and $12,700 for non-single coverage.

For plan years after 2014, the non-HSA OOPM will be indexed annually and will be subject to different indexing rules than for HSA plans. Beginning in 2015, the OOPM limits for non-HSA plans will be $6,600 for single coverage and $13,200 for non-single coverage.

All non-grandfathered plans must have an OOPM, and all member

cost sharing (copays, coinsurance, deductibles, per occurrence deductibles, etc.) must accumulate to a single, combined OOPM. Plans with network and non-network benefits need only count network benefits toward the OOPM. Plans will a single administrator for all benefits (for example: medical, pharmacy, behavioral health) must not exceed the combined OOPM.

However, a one-year compliance safe harbor is available if a plan uses separate service providers to administer plan benefits. Under the safe harbor, such plans will be deemed compliant for 2014 if the plan's major medical coverage has an OOPM of no more than $6,350/$12,700. To the extent that there is a separate OOPM for coverage administered by the separate service provider (for example, pharmacy), that OOPM cannot exceed the $6,350/$12,700 limits.

Cost sharing for behavioral health benefits must be combined with medical cost sharing into the single, combined OOPM.

Category: Insurance

Similar articles: