Under the Patient Protection and Affordable Care Act (ACA), members should
not be charged any cost-sharing (i.e., copayments, coinsurance,
and deductibles) once their annual limit for essential health benefits has been
met. Essential health benefits, as defined by the ACA, fall into ten categories
including medical benefits, prescriptions, pediatric dental services, and
pediatric vision services for those members whose benefits include these
services.
Annual limits are based on the member's benefit plan. While some member
benefit plan limits may be lower, beginning January 1, 2018, the annual
limits will be changed to the following amounts:
- Individual: $7,350
- Family: $14,700
Once members have reached their out-of-pocket maximum, providers should
not collect additional cost-sharing for essential health
benefits.
To verify if members have reached their out-of-pocket maximum, providers
should use the Eligibility and Benefits Inquiry transaction on the
NaviNet® web portal. Once on the Eligibility and Benefits
Details screen, the member's current out-of-pocket expense will be
displayed.
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