- Benefits administered by multiple vendors
Even if benefits are administered by separate vendors, the in-network OOP expenses for EHBs covered under the same health plan must accumulate to a single OOP maximum. However, if dental and vision are considered excepted benefits, their related expenses do not accumulate with medical expenses toward the OOP limits (see below for more details).
- MH/SUD Parity and OOP maximums
- Plans subject to MH/SUD Parity cannot have separate annual deductibles and OOP limits from medical benefits. The costs must accumulate to a single OOP maximum.
- If not subject to Parity, non-grandfathered plans must either:
- Keep the OOP limits separate and ensure the annual total of all OOP expenses does not exceed the allowed maximum, or
- Combine the out-of-pocket maximums
- Grandfathered plans are not required to cover MH/SUD services. However, if they do cover them, plans cannot apply annual or lifetime dollar limits because the services are considered EHBs.
- Out-of-pocket considerations for Health Savings Account (HSA) plans
In addition to following ACA maximum OOP limits, HSA-compatible high-deductible health plans (HDHPs) need to follow additional Internal Revenue Service (IRS) rules. HSA plans have minimum deductible and maximum OOP limits.
2019 2020 HDHP Minimum Deductibles $1,350 for individual
$2,700 for family
$1,400 for individual
$2,800 for family
HDHP OOP Maximums $6,750 for individual
$13,500 for family
$6,900 for individual
$13,800 for family
There are also special considerations for HSA-compatible HDHPs as it relates to the embedded individual OOP. Learn more here.
- Excepted Benefits
Excepted benefits are not subject to ACA requirements such as the expense limitations of OOP maximums. To determine whether dental or vision benefits are excepted benefits, read our FAQ here.