As of January 1, 2014, non-grandfathered health plans must cap annual out-of-pocket (OOP) expenses for deductibles, coinsurance and copays to $6,350/single and $12,700/family, with a single OOP limit applicable to all coverage, including medical, prescription drug, and mental health and substance use disorder benefits. This creates reporting and tracking issues for employers that use different vendors to carve out select benefits from their health plan, but the PPACA regulations allow for a safe harbor transition period during 2014.
The safe harbor transition rule stipulates that, for the first plan year beginning on or after January 1, 2014, separate medical and prescription drug plans may separately comply with the statutory maximum. A group health plan or an insurer may not impose an annual OOP limit on medical/surgical benefits and a separate annual OOP limit on mental health and substance use disorder benefits.
Only medical costs will accumulate to the OOP limit until 2015.
