Thursday, June 4, 2015

Single Out of Pocket Maximum to Apply to Every Individual on a Plan in 2016, Regardless of Coverage Level

This is from Benefit First:
The Department of Health and Human Services (HHS) has set the 2016 out-of-pocket (OOP) maximum for plan years starting on or after January 1, 2016, to $6,850 for self-only coverage and $13,700 for other than self-only coverage (family coverage). 
More importantly, the HHS guidance clarifies that the self-only OOP maximum will apply to each individual covered, regardless of whether the person's enrolled in single or family coverage. 
  • For Example: if the family OOP max is $13,000, and Mom incurs $10,000 in expenses, she is responsible for paying only the self-only OOP max, which is $6,850 in 2016. The plan pays the rest. 
This is a dramatic change for High Deductible Health Plans (HDHPs) eligible to be coupled with Health Savings Accounts.  Historically, virtually all HSAs apply a single family deductible and a family OOP maximum.  Hence, in the above example, Mom would be liable for the full $10,000 because $10,000 is still under the family deductible of $13,000.  

Based on this guidance, it appears that the most common historical HSA-compatible plan design will no longer be permitted.  HSA-qualified HDHPs will now need to include an embedded self-only OOP maximum to be compliant after December 31, 2015.

This new guidance will soften the blow on family deductibles at the point of service in 2016 but it will also increase premiums for HSA-eligible plans.