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Under the Patient Protection and Affordable Care Act, also known as Health
Care Reform, members should not be charged any cost-sharing (i.e., copayments,
coinsurance, and deductibles) once their annual limit for essential health
benefits has been met. Essential health benefits include medical benefits,
prescriptions, pediatric dental services, and pediatric vision services for
those members whose benefits include these services.
These limits are based on the member's benefit plan. While some member
benefit plan limits may be lower, they currently cannot exceed the following
amounts:
- Individual: $6,600
- Family: $13,200
Beginning January 1, 2016, the annual limits will be changed to the
following amounts:
- Individual: $6,850
- Family: $13,700
Once members have reached their out-of-pocket maximum, providers should not
collect additional cost-sharing for essential health benefits.
Out-of-pocket maximum calculations embedded for each
individual
In 2015, the total out-of-pocket maximum for some AmeriHealth plans
accumulated on an aggregate basis – meaning that one individual within a
family plan could have been required to pay out of pocket until the entire
family's out-of-pocket maximum was met.
In 2016, Health Care Reform regulations require an "embedded" in-network
out-of-pocket maximum for each individual to limit the amount of out-of-pocket
expenses that any one person will incur. This means that each member enrolled
in an individual plan, or any person in a family plan, will only pay the
in-network out-of-pocket maximum set for an individual and not be required to
pay out of pocket to meet the family in-network out-of-pocket maximum for the
plan. For a family plan, after one person meets the individual in-network
out-of-pocket maximum for their plan, the other family members continue to pay
out of pocket until the remaining in-network out-of-pocket maximum amount is
met.
To verify if members have reached their 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 (Accumulated Amount)
and the maximum dollar limit (Threshold Amount) will be displayed at the bottom
of the screen in the Benefit Accumulator section.
NaviNet is a registered trademark of NaviNet, Inc.
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