The Real Story on Out-of-Pocket Maximums

Originally posted by Linda Rowlings on

Last week several media outlets picked up a FAQ that the Department of Labor issued in February of this year. (The FAQ may be accessed here: FAQs About Affordable Care Act Implementation Part XII.)  Some of the reports have created confusion about the requirement, and the scope of what has been delayed; here is a summary of the rules:

Beginning in 2014, all non-grandfathered plans (whether fully insured or self-funded, and regardless of size) must have an out-of-pocket maximum that does not exceed $6,350 for single coverage and $12,700 for family coverage.  The out-of-pocket maximum includes the deductible, coinsurance and copays.  It may exclude out-of-network charges and excluded charges.

In response to industry comments that it would be difficult to integrate different vendors’ systems by 2014, the FAQ provides that if a plan uses different providers for medical and prescription drugs, it will not be required to integrate out-of-pocket maximums for 2014.  Instead, simply ensuring that the medical benefit meets the out-of-pocket maximum will suffice.  (Plans that have a common medical and Rx vendor are expected to apply both medical and Rx charges to a common out-of-pocket maximum.)  Because of existing rules under the Mental Health Parity Act, plans that use a separate vendor for mental and nervous disorder coverage should already have an integrated out-of-pocket maximum for medical and mental and nervous coverage, and the transition rule does not apply to this situation.


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