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