The Affordable Care Act requires non-grandfathered groups and individual plans to establish limits on member cost sharing for essential health benefits. These out-of-pocket maximum (OOPM) limits are updated on a yearly basis. Applies to: All non-grandfathered groups and individual health plans.
In 2019, those limits are as follows.
Non-HSA (Health Savings Accounts) or HDHP (High Deductible Health Plans) Plans
- $7,900 for self-only coverage. Note that the self-only OOPM applies to each individual, regardless of whether he or she is enrolled in self-only or family coverage.
- $15,800 for other than self-only (family) coverage.
High Deductible Health Plans have both a minimum deductible amount and an OOPM limit. Those limits remain unchanged from 2018:
- $1,350 minimum deductible and $6,550 OOPM for self-only coverage.
- $2,700 minimum deductible and $13,100 OOPM for other than self-only (family) coverage.