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 22 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
March 17, 2016
Health and Welfare Law
HHS Releases New
released the 2017 health plan out-of-pocket maximums. For plan years
beginning January 1, 2017, the out-of-pocket maximums are $7,150 for
self-only coverage and $14,300 for family coverage, up from $6,850
and $13,700, respectively, in 2016.
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 toward the ACA's cost-sharing limits.
However, premiums, balance billing amounts and non-covered health
services are not counted.
Beginning in 2016, HHS requires all group health
plans, whether self-funded or fully-insured, to have a self-only
cost-sharing limit within the family limit. (See our Alert of
Using the 2017 limits, if a family plan has an annual out-of-pocket
limit of $14,300 and one family member incurs a $20,000 expense, that
family member would be responsible for only $7,150 (i.e., the
self-only limit) and the remaining $12,850 would be paid by the plan.
The other family members would remain responsible for the remaining
$7,150 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
embedded self-only cost-sharing limit and the IRS's deductible and
out-of-pocket limits for self-only and family coverage.
2016, 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
2016 are $6,850 for self-only coverage and $13,700 for family
coverage. The IRS is expected to release the 2017 HDHP out-of-pocket
limit in May 2016.
for Plan Sponsors. Because the
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.