The Centers for Medicare & Medicaid Services has issued the final maximum out-of-pocket (“OOP”) limits that will apply to non-grandfathered group health plans for plan years beginning in 2026. The OOP limits are based on estimates of employer-sponsored health insurance premiums. They include the plan’s deductible and cost sharing for Essential Health Benefits (“EHBs”) under the Affordable Care Act (“ACA”). The definition of EHB has also been revised to exclude certain sex-based modification procedures.
OOP Limits. In general, the ACA requires non-grandfathered group health 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.
The final regulations update the methodology for calculating the “premium adjustment percentage” (which is used to set several ACA parameters) to align with premium trends, beginning in 2026. Based on this update, for 2026, the OOP limit for self-only coverage will be $10,600 (up from the proposed limit of $10,150), and $21,200 for family coverage (up from the proposed limit of $20,300).
Sex-Trait Modification Procedures. Beginning with the 2026 plan year, the term EHB will not include “specified sex-trait modification procedures.” The final regulations contain a definition of “specified sex-trait modification procedures.” HHS explains that this revision does not prohibit group health plans from voluntarily covering specified sex-trait modification procedures as non-EHB coverage when doing so is consistent with applicable state law.
