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 $7,900 for an individual plan and $15,800 for a family plan in 2019. The cap applies to essential health benefits obtained in-network.

Group health plans will be 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 $7,900 for self-coverage or $15,800 for a family plan in 2018. Note, however, that health plans cannot have a separate cap for mental health or substance use disorder services. (45 C.F.R. § 156.130; 81 Fed. Reg. 94058, Dec. 22, 2016; Dept. of Labor, FAQs About ACA Implementation (Part XVIII) and Mental Health Parity Implementation, Jan. 9, 2014).

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