OOP Limits and Marketplace Special Enrollment Period

The U.S. Department of Health and Human Services (HHS) has announced the inflation-adjusted maximum out-of-pocket (OOP) limits that will apply to non-grandfathered plans for plan years beginning in 2022.  The OOP limit includes the plan’s deductible and cost sharing for essential health benefits (EHBs) under the Affordable Care Act (ACA). HHS has also clarified the duration of the special open enrollment period for Marketplace coverage after the end of the new COBRA subsidies.

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 2022, the ACA OOP limit for self-only coverage will $8,700 (from the current 2021 limit of $8,550), and $17,400 for family coverage (from the current 2021 limit of $17,100). The limits apply to all OOP costs for in-network EHBs provided by non-grandfathered plans.

End of COBRA Subsidy Special Enrollment Period. Under the American Rescue Plan Act of 2021, a 100% subsidy for COBRA premiums is provided for a maximum six-month period beginning April 1 and ending September 30 for individuals who become eligible for COBRA due to an involuntary termination of employment or a reduction in hours worked. This subsidy is similar in many respects to the COBRA subsidy enacted in 2009 under the Obama administration except that the subsidy is greater and the administrative complexity is increased by the need to coordinate this subsidy with the extended deadlines for taking actions with respect to COBRA elections and COBRA payments. 

HHS has confirmed that a special enrollment period for ACA Marketplace coverage will be available when the COBRA subsidies completely cease.  The triggering event for this special enrollment period is the last day of the period for which COBRA continuation coverage was paid for or subsidized, in whole or in part, by an employer or a government entity. “Generally an individual will have 60 days to enroll after the individual knows, or should have known, of the [occurrence of the] triggering event.”