CMS Will Enforce Rule on Individual Out-of-Pocket Spending Caps

On Tuesday, CMS said it will enforce the Affordable Care Act’s cap on annual out-of-pocket health care spending for individuals, regardless of whether consumers have an individual or family health plan, Modern Healthcare reports.


In February, CMS released a wide-ranging final rule for the health insurance exchanges that finalized several consumer and insurer protections. Among other provisions, the rule capped maximum out-of-pocket costs at $6,850 for individual plans and $13,700 for family plans annually.

A Department of Labor document released in May clarified the policy, noting that even if a family health plan has a combined out-of-pocket cost limit of $13,700, no one individual on the plan can be liable for more than $6,850 in annual out-of-pocket costs.

According to Modern Healthcare, large employers have strongly opposed the cap on out-of-pocket spending, noting that they or the insurer are responsible for any additional costs.

The ERISA Industry Committee, a lobbying group that represents large companies, in a poll of its members found that about 70% of respondents would be “moderately or significantly affected” by such caps. ERISA Industry Committee CEO Annette Guarisco in a letter to the House Committee on Energy and Commerce wrote, “Some of our members will be forced to spend millions of dollars to make this change.”

CMS Will Enforce Cost Limits CEO Kevin Counihan in a letter sent to employers said CMS will enforce the new cost caps. He wrote, “We believe that applying the individual $6,850 maximum … helps remedy the difficulty a consumer could face in paying up to $13,700 out-of-pocket for certain covered medical care under the plan because he or she purchased family coverage instead of self-only coverage”

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