Skip to main navigation Skip to main content Skip to footer For Individuals & Families For Medicare For Providers For Brokers Español For Employers: For Employers Medical Savings and Spending Accounts (HRA/HSA/FSA) Wellness, Mental Health, and Behavioral Pharmacy Dental and Vision Cost Control Strategies Supplemental Health Solutions Who We Serve Overview Small Employers (51 - 499) Medium Employers (500 - 2,999) Large Employers (3,000+) Hospitals and Health Systems Higher Education K-12 Education State and Local Governments Taft-Hartley and Federal Membership and Affinity Groups Third Party Administrators Health Insurance for Expats IGO/NGOs Multinational Businesses Why Cigna Overview Industry Insights Overview Informed on Reform Workplace Wellness Consumer-Driven Health Plans Log in to Employer Portal
Home Employers Industry Insights for Employers and Brokers Informed on ReformEmbedded Out-of-Pocket Maximum

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. The 2020 ACA OOP maximum amounts are $8,150 for an individual and $16,300 for a family.

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

More information

Learn more about cost-sharing limits.

Page Footer

I want to...

Get an ID card File a claim View my claims and EOBs Check coverage under my plan See prescription drug list Find an in-network doctor, dentist, or facility Find a form Find 1095-B tax form information View the Cigna Glossary Contact Cigna

Audiences

Individuals and Families Medicare Employers Brokers Providers

Secure Member Sites

myCigna member portal Health Care Provider portal Cigna for Employers Client Resource Portal Cigna for Brokers

Cigna Company Information

About Cigna Company Profile Careers Newsroom Investors Suppliers Third Party Administrators International Evernorth

 Cigna. All rights reserved.

Privacy Legal Product Disclosures Cigna Company Names Customer Rights Accessibility Report Fraud Sitemap

Disclaimer

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., and Cigna HealthCare of North Carolina, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of Cigna Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna.

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.

Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna website. Cigna may not control the content or links of non-Cigna websites. Details