Health Care Reform

2015 Annual Cost-Sharing Limits for Coverage of Essential Health Benefits

Fact Sheet Provides Early Guidance

new rule issued by the U.S. Department of Health and Human Services (HHS) addresses, among other things, the requirement under the Affordable Care Act that non-grandfathered group health plans limit annual out-of-pocket cost-sharing for coverage of essential health benefits under the plan beginning in 2014. The law requires that these limits be updated annually.

Note: If allowed by a particular state and insurer, a small business may be able to renew its current group coverage that does not comply with the requirements related to essential health benefits and limits on cost-sharing, through policy years beginning on or before October 1, 2016.

For 2015, HHS updated the annual limits based on projections of average per enrollee health insurance premiums for employer-sponsored coverage. As a result:

  • Annual out-of-pocket expenses may not exceed $6,600 for self-only coverage or $13,200 for family coverage in 2015;
  • For small group plans, annual deductibles may not exceed $2,050 for self-only coverage or $4,100 for family coverage in 2015. (Certain small group plans may exceed the annual deductible limit if the plan cannot reasonably reach a given level of coverage, or metal tier, without exceeding the deductible limit.)

An HHS 2015 Health Policy Standards Fact Sheet is also available to provide early guidance for employers providing health coverage next year.

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