COST SHARING
Cost Sharing
The Affordable Care Act establishes annual limits on in-network out-of-pocket maximums on Essential Health Benefits (EHBs) for nongrandfathered plans. (This cost-sharing provision does not apply to grandfathered plans.) The annual out-of-pocket maximum applies to the plan on the first day of the first plan year. The in-network annual out-of-pocket maximum may be divided across multiple categories of benefits, provided the aggregate of all separate out-of-pocket maximums applicable to all in-network EHBs under the plan do not exceed the annual out-of-pocket maximums for that plan year.
Remember!
Self-funded group health plans are not required to cover Essential Health Benefits. But, if they do, they cannot impose lifetime or annual dollar limits on those benefits.
Annual Cost Share Limit for 2023 Plan Year
Maximum Annual Limitation on Cost Sharing for Plan Year 2023
A non-grandfathered group health plan’s in-network out-of-pocket maximum for EHBs for the 2023 plan year cannot exceed $9,100 for self-only coverage and $18,200 for other than self-only coverage, an increase of approximately 4.6% above 2022.
2022
A non-grandfathered group health plan’s in-network out-of-pocket maximum for EHBs for the 2022 plan year cannot exceed $8,700 for self-only coverage and $17,400 for other than self-only coverage. This is an approximately 1.8 percent increase above the 2021 parameters of $8,550 for self-only coverage and $17,100 for other than self-only coverage.
2021
A non-grandfathered group health plan’s in-network out-of-pocket maximum for EHBs for the 2021 plan year cannot exceed $8,550 for self-only coverage and $17,100 for other than self-only coverage, an increase of approximately 4.9% from 2020. The in-network out-of-pocket maximum applies to all individuals, regardless of whether an individual has a self-only plan or other-than-single coverage.
2020
A non-grandfathered group health plan’s in-network out-of-pocket maximum for EHBs for the 2020 plan year cannot exceed $8,150 for self-only coverage and $16,300 for other than self-only coverage, an increase of slightly more than 3 percent from 2019. The in-network out-of-pocket maximum applies to all individuals, regardless of whether an individual has a self-only plan or other-than-single coverage.
2019
A group health plan’s in-network out-of-pocket maximum for EHBs for the 2019 plan year cannot exceed $7,900 for self-only coverage and $15,800 for other-than-single coverage, an increase of 7 percent from 2018. The in-network out-of-pocket maximum applies to all individuals, regardless of whether an individual has a self-only plan or other-than-single coverage (including a high deductible health plan).