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2018 out-of-pocket maximums for commercial HMO, POS, and PPO members

December 21, 2017

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.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.


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