Frequently Asked Questions for Sponsors of Self-Insured Health Plans
What is Maximum Out-of-Pocket (“MOOP”)?
MOOP is the most that a plan member is required to pay for health care services during a plan year.
Which member costs are applied to a member’s MOOP?
The Patient Protection and Affordable Care Act (‘ACA”) has standardized which costs are applied to MOOP. All member cost-sharing payments for essential health benefits (“EHBs”) must count toward determining the member’s MOOP. These include copays, deductibles, and coinsurance. Premium payments by the member are not applied to the calculation of MOOP.
What are EHBs?
As defined in the ACA, EHBs are the ten categories of benefits that small group employers must cover as part of their health care plans. The ten categories are:
• Ambulatory services, such as doctor’s visits and outpatient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care
As a large group employer, is my company required to offer coverage for EHBs?
No, the ACA does not require large group employers to offer coverage for all ten categories of EHBs. However, if a plan offered by a large group employer covers any of the EHBs, the member cost-sharing for those EHBs must be applied to the member’s MOOP.
As the sponsor of a self-insured health plan, do I have to establish a MOOP? If so, how much does the MOOP have to be?
Yes, all health plans, whether fully- or self-insured, must establish a MOOP for their plan years that begin on or after January 1, 2014. The ACA provides that the MOOP cannot exceed the deductible limits established by the IRS for high-deductible health plans. In 2014, those limits are $6,350 for an individual and $12,700 for a family. The IRS adjusts these limits annually. You are allowed to set your plan’s MOOP below those limits.
Our plan uses separate third-party administrators for medical/surgical benefits and pharmacy. Can we have separate MOOPs for the benefits administered by different TPAs?
Yes, there is a safe harbor for 2014 for plans that use different companies to administer benefits. For 2014, the plan has several options:
• Establish a single MOOP for all categories of EHBs,
• Establish a MOOP that only applies to medical/surgical benefits, or
• Establish separate MOOPs for the benefits administered by different companies.
If the plan decides to establish separate MOOPs for the benefits administered by different companies, the total of all the MOOPs cannot exceed the maximum allowable amount for the year as described in the previous question.