Employers should be aware of three elements of recently-released final regulations from the HHS*. Issued by the Centers for Medicare and Medicaid Services (CMS), these regulations make changes to out-of-pocket maximums and prescription drug cost sharing, and also impact the health insurance Marketplaces.

Out-of-Pocket Maximums

Out-of-Pocket Maximums for ACA** required Essential Health Benefits in health plans for 2020 are $8,150 for self-only coverage, and $16,300 for family coverage for plans beginning on or after January 1, 2020. CMS reports that this is a 3.16% increase over the maximums for 2019.

Prescription Drug Cost Sharing

HHS has also issued a change to prescription drug benefits, which are considered Essential Health Benefits for health plans for 2020 designed to encourage enrollee’s use of lower-cost generic drugs. Health plans, including self-funded and fully-insured employer-sponsored plans, will be permitted (though not required) to exclude manufacturer’s coupons from counting toward the out-of-pocket maximum, provided that there is a medically appropriate generic available. This change is also subject to applicable state laws.

Marketplace Rules

The final regulations include provisions effective January 1, 2020, which could impact the health insurance Marketplaces. While changes to the Marketplaces do not directly impact employers, employers should continue to take note of employees accessing coverage on the Marketplaces and any Marketplace notices they receive from the IRS***.

We’re Here to Help

As always, American Fidelity is committed to providing our customers with up-to-date information on employee health and welfare benefits compliance. For more information about this and other regulatory developments, visit our website at HCReducation.com.





*U.S. Department of Health and Human Services
**Patient Protection and Affordable Care Act
***Internal Revenue Service