Earlier this week, the Department of Health and Human Services (HHS) published finalized 2021 Benefit Payment Parameters with an $8,550 out-of-pocket maximum for self-only coverage and $17,100 for family coverage for health plans beginning in 2021. See the 5/14/2020 Federal Register publication here.
Under the Affordable Care Act (ACA), non-grandfathered health plans are required to comply with an overall annual limit on out-of-pocket expenses for essential health benefits. The current limits, for 2020 plan years, is $8,150 for self-only coverage and $16,300 for family coverage.
The IRS has yet to release information on what the 2021 requirements will be for high-deductible health plans (HDHPs) and health savings accounts (HSAs). The HDHP/HSA requirements include a minimum deductible, a maximum out-of-pocket limit and a maximum HSA contribution amount. These requirements apply to both grandfathered and non-grandfathered group health plans.
Here's a summary of both traditional plans and HDHP/HSA plans for the 2020/2021 plan years:
If your plans offer both traditional and HDHP/HSA plans (that are not grandfathered), your plans are subject to both sets of requirements and you must ensure compliance with the lowest applicable out-of-pocket maximum. Plus, the ACA requires that a per person (individualized/imbedded) out-of-pocket maximum doesn't exceed the ACA limit, even if you are in the larger (family) tier.
The rule also finalizes the treatment of drug manufacturer support, including coupons, as it relates to the participant's maximum out-of-pocket exposure. We previously shared guidance (September 4, 2019) about this. Health plans have the ability/the option to determine whether they will count the value of a drug manufacturer's coupons/other assistance when determining if a participant has satisfied his or her cost-sharing obligations - provided that this is consistent with state law.