2016 Changes to Out-of-Pocket Health Insurance Limits


The Affordable Care Act requires non-grandfathered group health plans to limit out-of-pocket (OOP) expenses participants pay for in-network essential health benefits-- inclusive of money spent on deductibles, co-insurance and co-payments for in-network providers. For 2015, the limits are $6,600 individual and $13,200 family; for 2016, these limits increase to $6,850 individual and $13,700 family.

A significant additional change in 2016 is that non-grandfathered group health plans must apply an embedded self-only out-of-pocket maximum (OOPM) to each individual enrolled in family coverage if the plan's family OOPM exceeds the ACA's OOP limit for self-only coverage ($6,850 in 2016).

The example below illustrates the mechanics of an embedded individual OOPM, assuming $13,700 OOPM for family coverage:
  • Employee "Adam" incurs $8,000 in cost-sharing expenses (deductibles, copays and coinsurance). Adam pays the OOPM capped at $6,850, then benefit coverage without cost sharing starts for Adam and the plan pays the remaining $1,150.
  • Adam's spouse incurs $4,000 in cost-sharing expenses. Adam pays $4,000 (a total of $10,850 has now been satisfied toward the family OOPM) and the plan pays $0.
  • Adam's child incurs $3,000 in cost-sharing expenses. Adam pays $2,850 (family OOPM of $13,700 now satisfied) and the plan pays the remaining $150.
  • All additional in-network claims incurred during the rest of the plan year by Adam, his spouse, or child would be paid by the plan without any cost-sharing, because the family OOPM has been reached.

USHL Action Regarding 2016 OOPM Changes

USHL will not be increasing the 2016 OOPMs on any insured or SafeGuard plans to meet this higher 2016 limit-- all plan OOPMs will remain capped at $6,350 individual and $12,700 family. USHL will, however,  be applying an embedded self-only OOPM of $6,350 for all individuals in family coverage for the 2016 calendar year.

Questions? For additional information about the 2016 OOPM changes, click here, or contact USHL Sales Support at (844) 828-5968.

USHL transitional groups will begin receiving renewal packages mid-September; keep the following information in mind as you discuss these renewals with your group contacts:

  • Hardcopy documents will be mailed to the employer and an electronic copy sent to the group's agent; agents will receive renewal emails the weeks of September 7 and 14, and employers will receive renewal packages the weeks of September 14 and 21.
  • Employers can only renew as-is or select an alternate plan within the same plan family-- i.e. deductible level changes only.
  • The new plan year runs 12/01/2015 through 11/31/2016.
  • Employers electing to renew must submit to USHL a copy of the group's updated Wage and Tax Report on or before December 1, 2015. Employers must also complete and submit the Extended Transitional Policy acceptance form.
  • In order to ensure accurate post-renewal billing, changes must be submitted prior to October 31, 2015.
Contact USHL Sales Support or your General Agent for additional details-- 
click below for an agent contact directory. 
Agent Contact Directory

Prepare for MEC
Reporting Requirements

Beginning in early 2016, the IRS under the Affordable Care Act (ACA) will require groups to report on their Minimum Essential Coverage (MEC) and Applicable Large Employer (ALE) shared responsibility (IRS Code Sections 6055 and 6056).  Both of these reporting requirements apply to health care coverage provided in 2015, and preparations will need to begin this year.

Review more details in the May/June Healthy Headlines.

Explaining to employees their health insurer's
need for social security numbers

A component of the MEC reporting responsibility is the collection of social security numbers by health insurance providers.

Health insurance companies must collect social security numbers for each employee, as well as any covered spouses and children because the Affordable Care Act requires every provider of minimum essential coverage to report that coverage by filing an information return with the IRS and furnishing a statement to covered individuals. The information is used by the IRS to administer-- and individuals to show compliance with-- the health care law.

Additional information provided by the IRS can be obtained here.

Don't miss the
in effect

offering a
streamlined underwriting
process and
additional compensation
on new groups
with effective dates through October 1, 2015.

Click here
 for full details.
Ongoing Group Maintenance--
Current forms ensure processing efficiency!

Encourage your group contacts to utilize the most up-to-date forms for their ongoing group maintenance, such as processing new enrollments.

The USHL website forms page offers the most up-to-date forms available:

Pre- and Post-Sale Support

MI, IN, IL, WI and OH (non-EGP) Business



(844)  828-5968

EGP Business


 Sue LaCavera
(800) 229-2210 x 138

 Donna Sulhan
(800) 229-2210 x 119

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