Out of Pocket Maximum – New Regulation Regarding Individual Assessment of Out of Pocket
Non-grandfathered plans are required to include an in network maximum out of pocket, which reflect the maximum cost share a covered individual may be responsible for in a given plan year, and should include the plan’s deductible, coinsurance, and all copayments. In 2016, this amount will increase to $6,850 per individual, and $13,700 for family coverage. We expect the out of pocket to increase annually, however, clarification regarding family out of pocket assessment is recent. Notably, the regulation now applies the individual out of pocket to each member of a family unit, and requires plans to pay 100% of covered expenses once an individual, whether enrolled in a single or family unit, has met the individual out of pocket. Additionally, once a family’s out of pocket has been met, all covered expenses must be paid in full, regardless of whether or not all of the individuals of the family unit have met their maximum out of pocket.
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