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2019 out-of-pocket maximums for commercial HMO, POS, and PPO members  

February 11, 2019    

Under the Patient Protection and Affordable Care Act (ACA), providers should not charge a member any cost-sharing (i.e., copayments, coinsurance, and deductibles) once the member’s annual limit for essential health benefits has been met. Essential health benefits, as defined by the ACA, fall into ten categories including medical benefits, prescriptions, pediatric dental services, and pediatric vision services for those members whose benefits include these services.

Annual limits are based on the member's benefit plan. While some member benefit plan limits may be lower, as of January 1, 2019, for most members the annual limits were changed to the following amounts:

  • Individual: $7,900
  • Family: $15,800

Once a member has reached his or her out-of-pocket maximum, providers should not collect additional cost-sharing for essential health benefits.

To verify if a member has reached his or her out-of-pocket maximum, providers should use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal. Once on the Eligibility and Benefits Details screen, the member's current out-of-pocket expense will be displayed.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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