Embedded OOP Customer Impacts
Since 2016, most health plans cannot allow any individual, including those with family coverage, to spend more than the individual out-of-pocket (OOP) maximum expense established under the Affordable Care Act (ACA). Commonly referred to as an embedded individual OOP maximum, this rule could impact a family’s total health care expenses, especially if only one family member incurs high medical expenses.
How it works
Once an individual with family coverage meets the individual OOP maximum, the plan must pay 100% of all covered expenses for that person, even if the family maximum has not been met.
Once the family OOP maximum is reached the plan must pay 100% of all covered expenses for every covered individual — regardless of whether each family member has reached the individual maximum.
Considerations for Health Savings Account (HSA) plans
HSA-compatible high-deductible health plans (HDHPs) need to follow additional Internal Revenue Service (IRS) rules for OOP maximums. Those rules:
- Require deductible thresholds to be met before a plan begins to pay coinsurance
- Thresholds are set for 1) self-only coverage for individuals, and 2) family coverage for an entire family, including any covered individuals
- Allow a separate individual deductible that is at least as high as the minimum family deductible threshold
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Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative. This website is not intended for residents of New Mexico.