Reform Alerts - News from the Blues' Office of Health Reform

CMS releases final 2016 Maximum Out-of-Pocket Limits

May 14, 2015

On Feb. 20, the Centers for Medicare & Medicaid Services issued guidance establishing the maximum out-of-pocket limits for 2016.

The maximum out-of-pocket limit for self-only coverage is $6,850 (up from $6,600 in 2015). For coverage other than self-only (such as family coverage), the maximum out-of-pocket limit is $13,700 (up from $13,200 in 2015).

The final guidance clarifies that the out-of-pocket maximum limit for self-only coverage applies to all individuals (regardless of whether the individual is in self-only or family coverage). For example, a family plan with a $13,700 family out-of-pocket limit cannot have cost sharing exceed $6,850 for any individual enrollee on the contract.

The maximum out-of-pocket requirements apply to non-grandfathered individual market, small group, large group and self-funded group coverage.

The 2016 maximum out-of-pocket limits for health savings account-compatible high deductible health plans, which will likely be lower than the generally applicable requirement described above, are expected to be released by the IRS in May 2015.

For information, go to the final regulations.

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. As required by US Treasury Regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.