Note: Effective for plan years beginning on or after January 1, 2014; applies non-grandfathered plans only.

The ACA places annual limits on the total cost-sharing for essential health benefits for enrollees. Once the limitation on cost-sharing is reached for the year (also known as the out-of-pocket maximum), the enrollee is not responsible for additional cost-sharing for essential health benefits for the remainder of the year.  Cost-sharing includes any expenditure required by or on behalf of an enrollee with respect to essential health benefits, such as deductibles, medical copayments, prescription drug copayments, coinsurance and similar charges. It excludes premiums and spending for non-covered services.  For plans using provider networks, the final rule provides that an enrollee's cost-sharing for out-of-network benefits is not required to be counted toward the cost-sharing limit.

Out-of-Pocket Limits

ACA's cost-sharing limit is tied to the enrollee out-of-pocket maximum for HSA-compatible high deductible health plans (HDHPs). There are separate limits for self-only coverage and coverage other than self-only coverage (i.e. family coverage).  

  • For plan years beginning in 2015, the maximum annual limitation on cost sharing was $6,600 for self-only coverage and $13,200 for coverage other than self-only coverage.
  • For plan years beginning in 2016, the maximum annual limitation on cost sharing is $6,850 for self-only coverage and $13,700 for coverage other than self-only coverage.
  • For plan years beginning in 2017, the maximum annual limitation on cost sharing is $7,150 for self-only coverage and $14,300 for coverage other than self-only coverage.
  • For plan years thereafter, the maximum annual limitation on cost sharing is increased by the premium adjustment percentage described under Affordable Care Act section 1302(c)(4).

In the final HHS Notice of Benefit and Payment Parameters for 2016 (2016 Payment Notice), HHS clarified that under section 1302(c)(1) of the Affordable Care Act, the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self-only. Accordingly, the self-only maximum annual limitation on cost sharing applies to an individual who is enrolled in family coverage or other coverage that is not self-only coverage under a group health plan.

Compatibility with High Deductible Health Plans

Even though the ACA allows for out-of-pocket maximums up to the set limits previously outlined, Plan Sponsors need to be careful when draft a plan design for an HSA eligible high deductible health plan (HDHP).

Under the rules of an HSA eligible HDHP, the maximum out-of-pocket amount allowed is less than the cost sharing limitations under the ACA. Therefore, a HDHP with out-of-pocket amounts set at the ACA cost-sharing limitations would violate the rules of an HSA eligible plan.

  • For 2015 the HDHP maximum out-of-pocket amounts were $6,450 for self-only coverage and $12,900 for coverage other than self-only.
  • For 2016 the HDHP maximum out-of-pocket amounts are $6,550 for self-only coverage and $13,100 for coverage other than self-only.