As of 2014, the Affordable Care Act (ACA) places an overall limit on consumers' annual out-of-pocket costs for deductibles, co-payments, and co-insurance. This is sometimes referred to as the annual limit on out-of-pocket maximums or the new cost-sharing rules.
The 2014 cost-sharing annual limits are $6,350/year for individuals and $12,700/year for families.
Cost-Sharing Rules for 2015
The U.S. Department of Health and Human Services (HHS) has set the following cost-sharing parameters for 2015.
Out-of-Pocket Maximum: The maximum annual limit on cost sharing will be $6,600 for self-only coverage and $13,200 for family coverage. If a plan is non-grandfathered, out-of-pocket member/employee expenses for in-network essential health benefits (EHBs) cannot exceed these out-of-pocket limits.
Deductible Limit for Small Groups (1-50 employees): The maximum annual limit on small group deductibles will be $2,050 for self-only coverage and $4,100 for family coverage. Non-grandfathered small group plans must cap deductibles for in-network EHBs at these amounts.
Pediatric Dental Coverage: Stand-alone pediatric dental plans covering pediatric dental EHBs will have cost-sharing limits of $350 for coverage of one child and $700 for coverage of two or more children.
In 2014, the administration delayed the requirement (for some group health plans) to combine members' overall out-of-pocket spending into one total. As of 2015, employers and insurers need to make sure an employees' or members' out-of-pocket spending across multiple independent administrators does not exceed the 2015 cost sharing rules. Read more about the 2014 cost-sharing delay here.
These rules are outlined in the PPACA HHS Notice of Benefit and Payment Parameters for 2015 final rule, released March 11, 2014.