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Old 11-15-2015, 05:58 AM   #41
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Originally Posted by ziggy29 View Post
Example: You have a plan with a $5000 "individual" OOP maximum and a $10,000 "family OOP maximum. In the past, that could mean a self-only plan had a $5K limit but a family had a $10K limit even if only one of the insureds racked up the entire $10K.

Since the start of this year for "individual" health plans (and required in 2016 for group plans), in this plan the "embedded" individual OOP limit is $5K. Even in a family plan with a $10K OOP maximum, once any specific individual hits $5K in OOP costs, their cost sharing is done. Any additional expenses (in network) are covered 100% with no cost sharing, even if the "family" OOP max has not yet been met.
Please refer to the more accurate description below. The embedded MOOP is $6850 for 2016 unless the plan specifically states it is using the individual plan's MOOP.

Originally Posted by Katsmeow View Post
What is interesting is that for 2016 it is only the OOP of $6850 that has to be embedded. Imagine you had a policy that had an individual deductible of $3000 and a family deductible of $6000 and individual OOP of $6000 and family OOP of $1200. Theoretically as I understand it, the only thing the law requires is that on a family policy the individual's OOP would have to be no more than $6850. The insurer could still say it was using a family deductible of $6000 (and not a deductible of $3000 for an individual) and could say the individual in a family would have an OOP of $6850.

As I understood it, the insurer could embed the individual limits as they would be in an individual policy, but it isn't required to except for an OOP of $6850. What I'm finding difficult to determine is how the specific policies we are interested in are handling this.
Example provided by HHS:
Example: Assume that a family of four individuals is enrolled in family coverage under a group health plan in 2016 with an aggregate annual limitation on cost sharing for all four enrollees of $13,000 (note that a plan is permitted to set an annual limitation below the maximum established under section 1302(c)(1), which is an aggregate $13,700 limitation for coverage other than self-only for 2016). Assume that individual #1 incurs claims associated with $10,000 in cost sharing, and that individuals #2, #3, and #4 each incur claims associated with $3,000 in cost sharing (in each case, absent the application of any annual limitation on cost sharing). In this case, because, under the clarification discussed above, the self-only maximum annual limitation on cost sharing ($6,850 in 2016) applies to each individual, cost sharing for individual #1 for 2016 is limited to $6,850, and the plan is required to bear the difference between the $10,000 in cost sharing for individual #1 and the maximum annual limitation for that individual, or $3,150. With respect to cost sharing incurred by all four individuals under the policy, the aggregate $15,850 ($6,850 + $3,000 + $3,000 + $3,000) in cost sharing that would otherwise be incurred by the four individuals together is limited to $13,000, the annual aggregate limitation under the plan, under the assumptions in this example, and the plan must bear the difference between the $15,850 and the $13,000 annual limitation, or $2,850.

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Old 11-15-2015, 07:02 AM   #42
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So I take this to mean that when spending 5k to 10k (or more) for insurance that you should understand what you are buying. Last year I ended up calling the insurance company for plans (including ACA plans that I was considering) to figure out which one I was going to buy.
I do sometimes think that some of the insurance companies are trying to make this more confusing on purpose.
Last year I noticed the difference in embedded and aggregate... and for a bit did not remember which name went with which mechanism.
How many people here buy a car without learning at least the basics about the car? I do agree that insurance is a bit more complicated than it likely should be.

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