Compliance

2025 Maximum Out-of-Pocket Limits Released

November 21, 2023

On November 15, 2023, the Centers for Medicare and Medicaid Services (CMS) released the maximum limits on cost sharing for 2025 under the Affordable Care Act (ACA). ACA requires non-grandfathered group health plans to comply with a maximum annual limitation on cost sharing for essential health benefits (EHBs), often referred to as the out-of-pocket maximum.

The maximum out-of-pocket limit for plan years beginning in 2025 is $9,200 for self-only coverage and $18,400 for family coverage. This represents a 2.6% decrease from the limits of $9,450 and $18,900, respectively, for 2024 plans. Once the out-of-pocket maximum is reached for the year, an enrollee cannot be responsible for additional cost sharing for EHBs for the remainder of the year.

Enrollee expenses related to EHBs—such as deductibles, coinsurance, and copayments—must count towards the cost-sharing limit. However, health plans utilizing provider networks aren't obligated to include expenses from out-of-network benefits in this limit. Furthermore, ACA requires health plans to establish an embedded out-of-pocket limit for all enrolled individuals, ensuring that each person's limit on EHBs doesn't surpass the ACA's self-only out-of-pocket maximum.

Employers offering high deductible health plans (HDHPs) paired with a health savings account (HSA) must comply with IRS requirements on cost sharing for these plans. These requirements encompass a minimum deductible, a maximum out-of-pocket limit and a maximum HSA contribution amount. These requirements are applicable to both grandfathered and non-grandfathered group health plans. Typically, these figures are released in May or June of the preceding year, so anticipate their publication in spring of 2024 for plan years starting in 2025.

Reach out to your Hylant representative for further information. Don’t have one? Contact us here.

The above information does not constitute advice. Always contact your employee benefits broker or trusted advisor for insurance-related questions.

Authored By

Holly Wahl

EB Compliance Practice Leader

Contact Holly Wahl

Toledo

Holly leads Hylant’s ongoing efforts to provide our clients with exceptional compliance consulting services on new developments as well as ongoing requirements affecting health and welfare plans. She has a deep understanding of federal and state regulations pertaining to employee benefit plans, as well as extensive experience in group benefit plan operation.