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  • Home Employers Industry Insights Informed on Reform Embedded 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.

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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 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 The Cigna Group 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 Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna Healthcare.

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