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Mar 07

Jessica Rothe

2017 Out-of-Pocket Maximum (OOPM) Limits Announced

by Jessica Rothe

The Department of Health and Human Services (HHS) recently announced the 2017 Benefit Payment Parameters, which includes the limits for Out-Of-Pocket Maximums for Non-Grandfathered Health Plans (PPO/non-QHDHP) for 2017.

The below table summarizes the changes for Plan years that begin on or after January 1, 2017. 

OOPM Design

Current 2016 limits

New 2017 limits

$ Change

PPO/non-QHDHP Plans

ACA OOPM Limits

Individual: $6,850

Family: $13,700

Individual: $7,150

Family: $14,300

Individual: $300 increase

Family: $600 increase

QHDHP Plans

IRS OOPM Limits

Self-only coverage: $6,550

Family coverage: $13,100

IRS expected to release the OOPMs in May 2016*

* We will publish the QHDHP 2017 limits once released by the IRS.

Complying with Embedded OOPM rules:

Traditionally, IRS rules favored an aggregate approach to the deductible and OOPM limits for families enrolled in QHDHP plans requiring the full family deductible and OOPM to be met before the patient cost sharing was satisfied.  Beginning in 2016, all Non-grandfathered health plans are required to ensure that each individual’s Out-Of-Pocket limit does not exceed the limits provided under the ACA. 

Plans are required to implement an embedded OOPM per individual covered within the family, which cannot exceed the limits required under the ACA

The enforcement of the embedded OOPM is expected to increase in 2017, as Plans have had 2016 to get familiar with how to setup and administer embedded OOPMs. We look forward to partnering with our clients and provide guidance for Plan design to ensure compliance with these regulations.