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HorizonBlue-Logo-Updated-Jan15 2013

Horizon BCBS Broker Brief Notes
Applies to: All markets
August 22, 2014

Changes to Maximum Out-of-Pocket Limits

Under the Affordable Care Act (ACA), all non-grandfathered group health plans regardless of size orfunding arrangement, must comply with annual limits on out-of-pocket maximums for in-network covered services that are Essential Health Benefits (EHB)1. These out-of-pocket maximums are also known as a plan’s maximum out-of-pocket (MOOP).

All in-network copayments, coinsurance and deductibles for EHBs must accumulate to the MOOP.

MOOP Limits for 2015

For the 2015 plan year, the ACA requires that a group health plan’s member out-of-pocket expenses for in-network covered services – including medical, prescription drug and mental health/substance abuse benefits – must be capped at $6,600 for single coverage and $13,200 for non-single coverage. Because of federal mental health parity, some health plans may also be required to have a shared deductible and MOOP between medical and mental health benefits.

Health Savings Account (HSA) compatible high-deductible health plans must separately satisfy IRS requirements that cap the MOOP limit to $6,450 for single coverage and $12,900 for non-single coverage.

Plan Changes
Horizon Blue Cross Blue Shield of New Jersey is working toward full compliance with this new requirement. Group administrators of affected groups will soon receive a letter outlining Horizon BCBSNJ’s approach for implementing the ACA mandate. For our groups that offer major medical, prescription drug and mental health/substance abuse
benefits, Horizon BCBSNJ will update the programs so that all eligible in-network copayments, deductibles and coinsurance for in-network covered services provided by Horizon BCBSNJ will accumulate toward a consolidated MOOP on the group’s renewal/plan year date in 2015.

For our groups that have medical benefits with Horizon BCBSNJ and other EHB with other
vendors, federal guidance allows the group health plans to establish either:

• Separate MOOP accumulations for different categories of benefits, as long as the cumulative total of all the separate MOOPs do not exceed the applicable regulatory MOOP limit.


• A single integrated MOOP limit, not to exceed the applicable regulatory MOOP limit, toward which all benefit categories count. If your group health plan elects to use an integrated MOOP limit, your group health plan must facilitate the coordination of the different vendors that administer or manage different categories of benefits for your group health plan.

If a health plan is eligible to integrate, the Horizon BCBSNJ account manager will contact the group
to discuss the group health plan’s preferred approach for the MOOP limit for the 2015 plan year, and to discuss the timing and costs associated with integrating the MOOP limit with other vendors.

Integration may be limited in certain circumstances. Horizon BCBSNJ may not combine your
member’s out-of-pocket expenses if the benefit is with a carrier or administrator other than
Horizon BCBSNJ.
If you have any questions on this upcoming change, please contact your Horizon BCBSNJ
account manager.

1 NJ Minimum Standards regulation may require that all your in-network cost sharing, not only those attributable to EHB, accumulate towards the MOOP for insured arrangements. This communication is informational and educational in nature only. It does not constitute professional services, does not establish an attorney-client relationship, shall not be construed in any way as legal services and does not serve as a substitute for legal advice. No comment or statement in this communication or any accompanying materials is to be construed as legal advice and shall not constitute an admission. Horizon BCBSNJ reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. This communication provides only an overview. This publication and its materials also may not be fully updated to reflect the current state of law in any particular jurisdiction or circumstance as of the time of the publication. Furthermore, subsequent developments may impact the currency and completeness of this document. Horizon BCBSNJ disclaims, and has no responsibility to provide any update or otherwise notify any reader of any such change, limitation or other
condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this publication. Parties accessing this communications
are solely responsible for and are urged to engage competent legal counsel for consultation and representation in light of the specific facts and circumstances presented in their unique


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