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Small Business Employee Benefits and HR Blog

ACA Cost-Sharing Rules for 2015

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.cost_sharing_rules_aca_2015

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.

Health Care Reform Checklist for Employers 2014