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The Wagner Law Group

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 


Established in 1996, The Wagner Law Group has 26 attorneys engaged exclusively in employee benefits, estate planning and employment law. Six of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.





Contact Info

The Wagner Law Group


  Integrity | Excellence



Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110

Palm Beach Gardens 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418



Tel: (813) 603-2959

Fax: (813) 603-2961

101 East Kennedy Boulevard

Suite 2140
Tampa, FL  33602 


San Francisco

Tel: (415) 625-0002

Fax: (415) 358-8300

300 Montgomery Street

Suite 600

San Francisco, CA 94104


St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
100 South 4th Street, Suite 550
St. Louis, MO  63102 







December 29, 2016


 Health and Welfare Law Alert




     HHS Releases New Out-of-Pocket

Maximums for 2018






HHS has released the 2018 health plan out-of-pocket maximums. For plan years beginning January 1, 2018, the out-of-pocket maximums are $7,350 for self-only coverage and $14,700 for family coverage, up from $7,150 and $14,300, respectively, for 2017.


Background. The Affordable Care Act's ("ACA's") cost-sharing limits (i.e., the out-of-pocket maximums) are annual caps on the costs that non-grandfathered plans can require an individual to spend for covered essential health benefits. Co-payments, coinsurance, and deductibles generally count towards the ACA's cost-sharing limits. However, premiums, balance billing amounts and non-covered health services are not counted.


All group health plans, whether self-funded or fully-insured, must have a self-only cost-sharing limit within the family limit. (See our Alert of 3/26/15.)


EXAMPLE: Using the 2018 limits, if a family plan has an annual out-of-pocket limit of $14,700 and one family member incurs a $20,000 expense, that family member would be responsible for only $7,350 (i.e., the self-only limit) and the remaining $12,650 would be paid by the plan. The other family members would remain responsible for the remaining $7,350 of the total family deductible.


High Deductible Health Plans. Prior to ACA's enactment, high deductible health plans ("HDHPs") typically imposed one overall family out-of-pocket limit (i.e., an aggregate out-of-pocket limit) on family coverage without an underlying individual out-of-pocket limit for each covered family member. Sponsors of HDHPs must now comply with both the ACA's self-only cost-sharing limit and the HDHP's deductible and out-of-pocket limits for self-only and family coverage.


For 2017, the IRS's HDHP out-of-pocket limits are $6,550 for self-only coverage and $13,100 for family coverage whereas the ACA limits for 2017 are $7,150 for self-only coverage and $14,300 for family coverage. The IRS is expected to release the 2018 HDHP out-of-pocket limit in May 2017.


Takeaway for Plan Sponsors. Because IRS's HDHP out-of-pocket limits have historically been lower than the ACA-mandated out-of-pocket limits, many non-grandfathered plans have established a family out-of-pocket maximum at or below the HDHP limit but have implemented an individual out-of-pocket maximum for any individual enrolled in family coverage. Alternatively, some plans have retained one overall family out-of-pocket maximum but have set the family limit at or below the ACA's self-only out-of-pocket limit to avoid the possibility that an individual enrolled in family coverage exceeds the ACA limit.






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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.