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.
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