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The Wagner Law Group Description 

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 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.






Contact Info

The Wagner Law Group


  Integrity | Excellence


Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110

Florida Office 

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


San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104







March 26, 2015


 Health and Welfare Law Alert





HHS Guidance Clarifies ACA's

Cost-Sharing Rules





HHS has released final regulations and a Q&A that provide clarification of the application of the annual cost-sharing limits implemented by the Affordable Care Act ("ACA"). Notably, the final regulations indicate that the ACA's annual cost-sharing limit for self-only coverage applies to all individuals, including each individual who has family coverage. That is, the final regulations require group health plans to embed an individual cost sharing limit within the family limit.


Background. The ACA requires that all non-grandfathered group health plans have an annual cost sharing limit for covered, in-network essential health benefits that, for 2016, does not exceed $6,850 for self-only coverage and $13,700 for family coverage. Prior to HHS' release of the final regulations, many group health plan administrators had applied a single limitation depending on whether the employee enrolled in self-only or family coverage. Typically, if an employee enrolled in family coverage, the higher limit applied to the family as a whole, regardless of the expenses incurred by any single covered individual.


Final Regulations. For 2016, the HHS requires group health plans to have a self-only cost-sharing limit within the family limit.


EXAMPLE: Using the 2016 limits, if a family plan has an annual out-of-pocket limit of $13,700 and one family member incurs a $20,000 expense, that family member would be responsible for $6,850 (i.e., the self-only limit) and the remaining $13,150 would be paid by the plan. The other family members would remain responsible for the remaining $6,850 of the total family deductible.


High Deductible Health Plans.  Sponsors of High Deductible Health Plans ("HDHPs") that are intended to be compatible with Health Savings Accounts ("HSAs") should note that the out-of-pocket limits set for HSA-compatible HDHPs are lower than the ACA limits. For 2015, the HDHP limits are $6,450 for self-only coverage and $12,900 for family coverage whereas the ACA limits for 2015 are $6,600 for self-only coverage and $13,200 for family coverage.


Unlike these recent HHS rules for the ACA, the rules for HDHPs currently do not require that family HDHPs embed a self-only cost-sharing limit. Nevertheless, a family HDHP would satisfy both the HDHP and ACA limits only by including the new HHS' self-only cost-sharing limit requirement.


Action Steps for Plan Sponsors. The preamble to the final regulations indicates that "2016 plans must comply with this policy," thereby implying that compliance with the embedded self-only cost-sharing limit is not required until 2016 plan or policy years. Plan sponsors must be cognizant of this rule when working on 2016 plan designs and when pricing their plans.






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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.