Delay on ACA Out-of-Pocket Maximum: Blessing or Curse?
By Lauren Flynn Kelly - August 22, 2013

An article that appeared in The New York Times recently called attention to a little-known delay on the implementation of a provision of the Affordable Care Act. This one pertains to out-of-pocket limits on consumer spending and requires health plans and employers to set an overall maximum, as opposed to separate limits for medical and pharmacy expenditures.

The one-year grace period allows plan sponsors to delay setting the annual overall spending cap, which includes deductibles and copayments, at $6,350 for an individual and $12,700 for a family, until the 2015 plan year. More information about the grace period, which the Times gripes “was obscured in a maze of legal and bureaucratic language that went largely unnoticed,” is available as part of a series of frequently asked questions about the health care reform law that can be found at the Department of Labor website.

As it turns out, those FAQs were issued in February, so this isn’t really news per se, but it’s created a media frenzy of bloggers and journalists bemoaning yet another delayed provision of the Affordable Care Act. And the Times isn’t wrong: The language is confusing.

From what I understand, if a group health plan uses more than one benefit service provider, such as a health insurer and a PBM, separate spending caps could be established for major medical expenses and prescription drugs in 2014. The exception does not apply to individual plans. While patient advocates worry that the delay could cause considerable hardship for those with chronic conditions, it may give plan sponsors more time to iron out logistical dilemmas that arise from moving to a separate system of tracking pharmacy and medical out-of-pocket cost maxes to aligning those efforts to track overall expenditures.

What administrative difficulties will this provision create for plans, and is the one-year grace period likely to help their efforts to comply?

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