HHS Benefit and Payment Parameters Notice Clarifies Benefit Limits for 2018

Final regulations issued by the U.S. Department of Health and Human Services (HHS) made several changes to various Affordable Care Act (ACA) marketplace rules. Included in the rule were the 2018 out-of-pocket maximums (OOPMs) for nongrandfathered health plans.

healthcareThe OOPMs increased by 2.8% and are as follows:

Coverage Tier 2017 2018
Self-Only $7,150 $7,350
Other than Self-Only (for example, Family) $14,300 $14,700

Keep in mind that the HHS continues to enforce the embedded individual OOPM rule. That mandate requires nongrandfathered plans to have embedded individual OOPMs within the family OOPMs.

In other words, once any covered individual in the family coverage tier reaches the individual OOPM, that person’s expenses must be paid at 100%, even if the family coverage tier has a higher OOPM.

Recall also that if an employer offers a health savings account-eligible high deductible health plan (HDHP), those OOPMs are lower. The ACA OOPMs are indexed using a premium adjustment percentage; HDHP OOPMs are indexed using the Consumer Price Index.

For 2017, HDHPs have the following OOPMs:

Coverage Tier 2017 2018
Self-Only $6,550 N/A
Other than Self-Only (for example, Family) $13,100 N/A

Finally, as can be stated with any ACA-related regulations, this guidance is subject to change depending on legislation that might be passed this year that alters the ACA.