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2019 Out-of-Pocket Maximum Limits

The in-network out-of-pocket maximum (OOP), which applies to non-grandfathered group health plans,* is the annual limit on cost sharing that can be imposed on participants for their health coverage. Once a participant has paid cost sharing (deductibles, copays and coinsurance) equal to the out-of-pocket maximum, the plan must pay 100 percent of that participant's covered health expenses for the remainder of the benefit year. The out-of-pocket maximum, like the plan deductibles, resets at the start of a new benefit year.

 


*The requirements do not apply to excepted benefit plans, retiree plans or plans which have retained grandfathered status.

 

The table below shows the maximum allowed OOP amounts for single and family coverage for non–high deductible health plans (non-HDHP) in 2019, as compared to 2018:

 

20182019
Single Family Single Family
Non-HDHP $7,350 $14,700 $7,900 $15,800


Keep in mind, individual members may not be expected to pay more than the single OOP maximum, even if they are enrolled under family coverage. It is also important to remember that HSA-qualified HDHPs have slightly different limits ($6,750/$13,500) for their plans.

 

Please contact your Client Management team if you have any questions.