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 began 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 2015, those limits are $6,600 for an individual and $13,200 for a family. The IRS adjusts these limits annually. You are allowed to set your plan’s MOOP below those limits.
In 2014, there was a safe harbor for plans that use separate third-party administrators for medical/surgical benefits and pharmacy. Has that safe harbor been changed?
Yes, there are changes to the 2014 safe harbor for plans that use different companies to administer benefits. Beginning with plan years starting on or after January 1, 2015, all EHBs must be subject to MOOP. However, if your plan uses separate administrators, you can still 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.