Impacts of integrated disbursement for the client

Impacts of integrated disbursement for the client

Impacts of integrated disbursement for the client

As of 2016, most health plans cannot allow any individual, including those with family coverage, to spend more than the individual maximum out-of-pocket (OOP) set by the Affordable Care Act (HERE). 

This rule, commonly known as the integrated individual maximum out-of-pocket, could affect a family’s total health care expenses, especially if only one member of the family incurs high medical expenses. The maximum out-of-pocket amounts under the 2020 ACA are $8,150 for individuals and $16,300 for families.

How does it work

When an individual with family coverage has reached the individual out-of-pocket maximum, the plan must pay 100% of all covered expenses for that person, even if the family maximum has not been met.

Once the family out-of-pocket maximum is reached, the plan must pay 100% of all covered expenses for each covered individual, regardless of whether each family member has reached the individual maximum.

Considerations for Health Savings Account (HSA) Plans

HSA-compatible high-deductible health plans (HDHPs) must follow additional IRS rules for out-of-pocket maximums. Those rules:

  • Require minimum deductible values ​​to be met before the plan begins to pay coinsurance
  • The minimum values ​​are established for 1) individual coverage for a single person and 2) family coverage for an entire family, which includes any covered individual
  • Allow for a separate individual deductible that is at least as high as the minimum family deductible limit

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