Notes on the Affordable Care Act (ACA) Out-of-Pocket (OOP) Maximums & Affordability Limits for 2021

Last month, the Notice of Benefit and Payment Parameters for 2021 from the U.S. Department of Health and Human Services (HHS) went into effect. Among other things, this notice provides adjustment factors that determine cost-sharing limits for the Affordable Care Act (ACA)’s out-of-pocket (OOP) maximums. An OOP maximum is the highest out-of-pocket amount paid for covered services during a benefit period. Employers, as you prepare for the 2021 plan year, note the 2021 ACA OOP maximums in both plan budget planning and plan design.

The ACA OOP limit amounts for 2021 are as follows:

  • Self-coverage: $8,550
  • Family coverage: $17,100

These numbers are an increase of 4.9% from 2020 OOP maximums, and these limits apply to all OOP costs for non-grandfathered plans. It is important to note that the OOP amount for self-coverage is also the individual in-network OOP maximum for each individual in a family plan.

As a reminder, the IRS-determined OOP limits for high-deductible health plans (HDHPs) qualifying to work with health savings accounts (HSAs) for 2021 must be lower than the ACA limits. They are $7,000 for self-coverage only and $14,000 for family coverage. We talk about this in more detail, along with the 2021 HSA contribution limits, in a previous blog post.

Equally important to the planning process is maintaining compliance with the ACA Affordability standard. Under the ACA’s employer shared responsibility rules, applicable large employers (ALEs) are required to offer affordable, minimum value health coverage to their full-time employees and dependent children to avoid paying a penalty. For plan years that begin on or after January 1, 2021, the affordability percentage is 9.83%. This is an increase from 2020 when it was 9.78%, which may provide employers with additional flexibility in setting their employee contributions for 2021.

If you have any questions about ACA OOP maximums for 2021, contact the Employee Benefits Management Group (EBMG) at Rose & Kiernan, Inc. here or by calling (800) 242-4433.

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