Monday thru Friday . 8:00 AM - 5:00 PM EST
To our policyholders in areas affected by the recent hurricanes, please know that the thoughts and prayers of everyone at Aflac are with you. We are working with government agencies that represent all declared disaster areas to ensure we do everything possible to help you. Based on that guidance, we have extended the due dates for policy premiums by 60 days for those living in places that have been declared disaster areas. If you have a question about your policy or need help, contact us at 800-992-3522. To help with the recovery, Aflac made a $500,000 donation to the American Red Cross, and our employees are making their own private contributions. Please be safe, as the care of you and your families is paramount.
The Affordable Care Act (ACA) established out-of-pocket limits to protect consumers from runaway medical costs. The limits include essential health benefits covered under nongrandfathered plans, but out-of-network procedures or treatments not covered under an individual’s plan can still cost consumers more than the established limits. Here are the important details employers and employees need to know.
The limits reflect the most an individual or family will pay for covered essential health benefits before their plan begins to pay 100 percent of the costs. The limits are adjusted each year.
Covered essential health benefits are included in the out-of-pocket maximum. This includes deductibles, coinsurance, copayments or similar charges, and any other expenditure required of an individual that is a qualified medical expense for essential health benefits, which includes items and services in the following 10 categories:
Yes. Out-of-pocket limits do not count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for nonessential health benefits. That means patients can rack up bills for procedures, treatments or prescriptions not covered under their plan or outside of their network. These costs won’t count toward their out-of-pocket limit but can directly affect their wallet.
Starting in 2016, the individual limit was extended to each member of a family plan. This means that an individual’s out-of-pocket expenses covered under their plan will not exceed the individual limit, and a family’s out-of-pocket expenses covered under their plan will not exceed the family out-of-pocket maximum when they are added together.
Consider Family A has an out-of-pocket maximum of $14,300 and their family members incur the following covered in-network and non-network out-of-pocket expenses:
Individual 1’s out-of-pocket costs covered under their health insurance are capped at the individual maximum of $7,150. Even though family members 2, 3 and 4 don’t meet the individual out-of-pocket maximum by themselves, together the family’s out-of-pocket expenses for covered procedures and treatments would not exceed the family maximum of $14,300.
*The individual is NOT responsible to pay this amount.
However, since the family incurred $3,500 in non-network expenses and nonessential health benefit costs, these costs are the family’s responsibility and do not count toward the family’s out-of-pocket maximum cap.
Voluntary insurance is designed to complement an individual's major medical plan. These benefits work hand in hand with major medical plans to help make sure individuals who are sick or hurt have the funds they need to pay health-related costs their primary insurance might not cover, such as daily living expenses, like bills and groceries, as well as medical deductibles and insurance copayments, expenses major medical insurance isn’t designed to cover.
This material is intended to provide general information about an evolving topic and does not constitute legal, tax or accounting advice regarding any specific situation. Aflac cannot anticipate all the facts that a particular employer or individual will have to consider in their benefits decision-making process. We strongly encourage readers to discuss their HCR situations with their advisors to determine the actions they need to take or to visit healthcare.gov (which may also be contacted at 1-800-318-2596) for additional information.
This article is for informational purposes only and is not intended to be a solicitation.