Under the Patient Protection and Affordable Care Act, also known as Health Care Reform, 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 include medical benefits, prescriptions, pediatric dental services, and pediatric vision services for those members whose benefits include these services.

These limits are based on the member?s benefit plan. While some member benefit plan limits may be lower, they currently cannot exceed the following amounts:

• Individual: $6,850
• Family: $13,700

Beginning January 1, 2017, the annual limits will be changed to the following amounts:

• Individual: $7,150
• Family: $14,300

Once members have reached their out-of-pocket maximum, providers should not collect additional cost-sharing for essential health benefits.

Out-of-pocket maximum calculations embedded for each individual

Please keep in mind that Health Care Reform regulations require an ?embedded? in-network out-of-pocket maximum for each individual to limit the amount of out-of-pocket expenses that any one person will incur. This means that each member enrolled in an individual plan, or any person in a family plan, will only pay the in-network out-of-pocket maximum set for an individual and not be required to pay out of pocket to meet the family in-network out-of-pocket maximum for the plan. For a family plan, after one person meets the individual in-network out-of-pocket maximum for their plan, the other family members continue to pay out of pocket until the remaining in-network out-of-pocket maximum amount is met.

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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