The U.S. Department of Health and Human Services (“HHS”) has announced the proposed maximum out-of-pocket (“OOP”) limits that will apply to non-grandfathered plans for plan years beginning in 2025. The OOP limits are based on estimates of employer-sponsored insurance premiums. They include the plan’s deductible and cost sharing for Essential Health Benefits (“EHBs”) under the Affordable Care Act (ACA).
OOP Limits. In general, the ACA requires non-grandfathered plans to apply an embedded OOP limit for everyone enrolled in coverage. Each enrollee must have his or her own individual OOP limit on EHBs that is not higher than the maximum self-only OOP limit. For example, if an individual enrolled under family coverage reaches the applicable ACA OOP limit for self-only coverage, that individual cannot incur additional OOP costs for EHBs, even if the family OOP limit has not been met.
For 2025, the ACA OOP limit for self-only coverage will be $9,200 (down from the 2024 limit of $9,450), and $18,400 for family coverage (down from the current 2024 limit of $18,900).
