The document summarizes regulations from the Department of Health and Human Services regarding deductible and out-of-pocket limits under the Affordable Care Act. For 2014, the maximum deductible is $2,000 for individual plans and $4,000 for family plans. The maximum out-of-pocket limit is $6,250 for individual plans and $12,500 for family plans. These limits apply to small group plans but not large group or self-funded plans. The deductible limits take effect for plan years beginning on or after January 1, 2014.

1. January 1, 2014 Deductible and Out of Pocket Requirement Summary
The U.S. Department of Health and Human Services (HHS) posted final regulations about the deductible and
out-of-pocket limitations to the Federal Registrar on February 25, 2013. Section 1302(c) of the Affordable Care
Act (ACA) specifies that the maximum deductible for a qualified insurance plan cannot exceed $2,000 for
single coverage and $4,000 for family coverage.It also indicates that maximum out-of-pockets cannot
exceed that of a HSA-qualified plan.The maximum out-of-pocket for a HSA-qualified plan in 2013 is
$6,250 for single coverage and $12,500 for family coverage.The deductible and out-ofpocket limitations are subject to annual inflationary adjustments.
Small Group Deductible and Out of Pocket
The final regulations provide clarification that the deductible limitationsonly
apply to
non-grandfathered small group health plans. These would be plans offered by
employers in most statesthat have fewer than 50 full-time equivalent employees (unless a
state raises that to 100 employees).
The guidance also suggests that issuers of coverage in the small group market may exceed the annual
deductible limit if it would be necessary to achieve a qualification as a bronze, silver, gold or platinum
plan.These "metallic" plans must provide coverage that meet minimum actuarial value (AV) requirements. AV
is defined as the percentage of health care expenses a plan would cover on average for the standard population
and will range between 60-90% based on the coverage tier.
Large Group and Self Funded Plans Deductible and Out of Pocket
At this time, largeemployer plans (a firm with 50+ full-time equivalent
employees) and self-funded plans do not need conform to these deductible
limitations. However, the proposed regulations do indicatethat the out-of-pocket limitations will
applyto all non-grandfatheredgroup health plans including small group plans, large group plans and
self-funded plans, as well asindividual health plans.
Deductible and Out of Pocket Effective Dates for a Plan
The maximum out-of-pocket limitation requires that the deductible, coinsurance and
copay expenses apply towards meeting the out of pocket. These new requirements apply to
the first plan year that begins on or after January 1, 2014.
The U.S. Department of Labor has published a Frequently Asked Questions (FAQs) document about the new
guidance. View FAQs regarding ACAimplementation >>
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