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: $6,850
- Family: $13,700
Beginning January 1, 2017, the annual limits will be
changed to the following amounts:
- Individual: $7,150
- Family: $14,300
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
Please keep in mind that 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 will be
displayed.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.