FAMILY PLANS MUST EMBED OUT-OF-POCKET LIMITS IN 2016

By June 17, 2015 August 19th, 2016 Life & Health Insurance

Early signs, HHS guidance, and Department of Labor information all point to the fact that all health plans, both large and small, must comply with the Family Out-Of-Pocket (OOP) maximum being embedded starting with plan year effective dates in 2016.  Embedded means that a single member of a family contract must be cut-off at the single OOP max limit, even if that contract is a family.

Let’s use an HSA or qualified high-deductible health plan (QHDHP) as an example.  Under traditional HSA plans, one member of a family on a family contract could meet the deductible entirely.  There is no cutoff at the individual level.  Same holds true for deductible and OOP max limits.  Under this new legislation, a single member of a family contract must be capped at $6,850 in 2016, regardless of contract type.

While this seems like an upgrade and benefit enhancement on the surface, it has it’s cons.  #1 – this will result in rather significant premium increases within the two-party plus and family contract tiers; #2 – carriers trying to administrate these multiple levels, or layers, of limits are going to struggle mightily; and #3 – timing of claims processing and submission by the providers becomes even more critical, not to mention, the processing of the claim within the insurance carrier.  This will be something we all want to keep our eye on, as it has significant effects on our QHDHP and HSA plans.