The COBRA Blog

PPACA Update: New Out-of-Pocket Limits Present Administrative Challenge

Posted by Robert Meyers on Wed, Apr 17, 2013 @ 12:04 PM

A recent rule Affordable Care Act (ACA) rule limits the out-of-pocket expenses that group health care plan providers can ask employees to pay.

The new rule is just one of the latest developments in the health care reform law regulations issued by the U.S. Department of Health and Human Services, and will require a flat dollar limit for all employer group health plans. This limit encompasses deductibles, copayments, coinsurance, and prescription drugs employees will be required to pay.

This is significant because today very few employers include copayments when they establish limits for employee out-of-pocket expense levels.

Under the new law, the annual out-of pocket limit on healthcare expenses that can be shifted to the employee cannot exceed the maximum limits allowed for that year. These new limits will apply only to new plans, and the existing grandfathered plans will eventually be phased out. Currently, the 2013 maximum limit for an HSA high-deductible plan for single-coverage employees is $6,250 and $12,500 for families. The new 2014 limits that employers and plan administrators will need to comply with are scheduled to be released by the Internal Revenue Service sometime in May.

One of the greatest challenges facing employers regarding this new law involves the coordination of benefits between many health plan providers. With federal regulations setting an overall limit on the out-of pocket expenses employees are required to pay, employers will have to maintain stringent records so they can continually be made aware of the various expenses that their employees are paying out-of-pocket.

For example, if an employee is required to pay a copay at the time of an office visit, the health care provider won’t be able to determine whether or not the employee has already met their plan’s annual limit of out-of-pocket expenses, and could continue to charge the copay regardless, even though the limit has been met.

It’s this type of disconnect that’s going to require communication and coordination between health care providers and plan administrators to link, coordinate, and document administrative services across all touch-points and in real-time.  As with all the health care regulations going into effect in 2014, employers and plan administrators should strive to establish proactive practices now, to avoid compliance hassles later.

Have you subscribed to the COBRA Blog yet? Stay informed on the latest developments in COBRA administration and PPACA by subscribing today. Just enter your email address in the subscribe box in the top left corner of this screen.

Tags: ppaca, cobra administration, cobra blog, PPACA update

describe the imagedescribe the image

Subscribe to the COBRAGuard Blog

Latest Posts

Posts by category

Follow Us