Affordable Care Act Out-of-Pocket Maximum Rules For All Markets

Affordable Care Act Out-of-Pocket Maximum Rules

Non-grandfathered group health plans that offer essential health benefits (EHBs) must comply with annual out-of-pocket expense limits for any in-network EHBs and out-of-network emergency services they cover starting with the group’s 2014 plan year, according to the federal government’s interpretation of the Affordable Care Act (ACA).

Important Note: Large group self-funded plans and groups that are grandfathered do not have to cover EHBs in 2014. However, non-grandfathered groups that cover EHBs are required by Affordable Care Act to follow Out Of Pocket Maximum rules starting with the 2014 plan year. ACA’s OOPM requirements do not apply to grandfathered plans and limited-scope dental and vision coverage structured as “excepted benefits.”

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