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Out-Of-Pocket Maximum

Out-Of-Pocket Maximum Limit

For plan years beginning on or after January 1, 2015, annual out-of-pocket (OOP) maximums for all plans may be no higher than $6,600 for self coverage and $13,200 for family coverage. These amounts are subject to change every year as determined by the IRS. All benefits contribute to the OOP maximum, including prescription benefits.

Year

OOP Maximum Limit
(Self Only)

OOP Maximum Limit (Family)

2014

$6,350

$12,700

2015*

$6,600

$13,200






*High deductible health plan out-of-pocket maximum limits for 2015 will be $6,450 and $12,900 for self-coverage and family coverage, respectively. 

If a group health plan or group health insurer has more than one service provider to administer benefits, such as carved-out pharmacy benefits, ACA requirements will be complied with if:

  • Major medical coverage complies with the OOP limits
  • Cost-sharing for any separate coverage, such as pharmacy, does not exceed the OOP limits

Under a special transition rule, however, plans currently using multiple claim payers, such as medical third-party administrators and separate pharmacy benefit management, have until the 2015 plan year to design a single OOP maximum and coordinate vendor arrangements.

Note: Grandfathered plans are not required to meet this provision.