QUESTION

I thought there was a cap on my out-of-pocket costs, but I’m getting billed for something that puts me well above the limit. How can that be?

Post enrollment issues | Employer-Sponsored Coverage
ANSWER

All new (i.e., not grandfathered or grandmothered) plans must limit out-of-pocket costs to $7,350 for individuals and $14,700 for a family in 2018 for services that are considered part of the essential health benefits and that are obtained in-network. There are a few possible explanations for why you are getting billed for something that puts you above the limit.

First, if you obtained an item or service not considered part of the essential health benefits, or received care out-of-network, your health plan is not required to apply those costs towards the limit on your out-of-pocket costs. Plans can also exclude non-covered services.

Second, it’s possible that your plan is grandfathered or grandmothered and doesn’t have to comply with this rule. Finally, if your plan has separately administered benefits, for example, for prescription drug coverage, it can have separate out-of-pocket limits, but the total of all caps combined cannot be more than $7,350 for an individual or $14,700 for a family in 2018. Check the details of your plan to see how the out-of-pocket limit is applied in your coverage. Your Summary of Benefits and Coverage will provide that information. (45 C.F.R. § 147.140; 81 Fed. Reg. 94058, Dec. 22, 2016).

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