QUESTION

I thought there was supposed to be a cap on my out-of-pocket costs, but when I look at my plan options, it looks like there is more than one cap, depending on what health care I use. How can that be?

Individuals with coverage | Coverage for Employees of a Large Employer
ANSWER

All non-grandfathered group health plans must cap out-of-pocket costs at $8,700 for an individual plan and $17,400 for a family plan in 2022. The cap applies to essential health benefits obtained in-network.

Group health plans are allowed to separate the total cap among benefits. For example, there can be a cap on out-of-pocket costs for medical benefits and a separate cap for prescription drugs, but combined, they cannot exceed the out-of-pocket spending cap of $8,700 for an individual plan or $17,400 for a family plan in 2022. Note, however, that health plans cannot have a separate cap for mental health or substance use disorder services. (45 C.F.R. § 156.130; CMS FAQs about ACA Implementation Part 46, June 4, 2021. Dept. of Labor, Jan. 9, 2014; 84 Fed. Reg. 17454, April 25, 2019).

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