The Wagner Law Group
Wagner Law Group, A Professional Corporation, is a nationally
recognized ERISA & employee benefits, estate planning,
employment, labor & human resources practice.
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.
Wagner Law Group
Fax: (561) 293-3591
7108 Fairway Drive
Palm Beach Gardens, FL 33418
East Kennedy Boulevard
Tampa, FL 33602
Francisco, CA 94104
100 South 4th Street, Suite 550
St. Louis, MO 63102
December 29, 2016
Health and Welfare Law
Releases New Out-of-Pocket
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.
group health plans, whether self-funded or fully-insured, must have a
self-only cost-sharing limit within the family limit. (See our Alert
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.
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.
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.
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.