Compliance
Maximum Out-of-Pocket Limits Increase Significantly in 2026
November 4, 2024
On October 8, 2024, the Centers for Medicare and Medicaid Services (CMS) released the maximum limits on cost sharing for 2026 under the Affordable Care Act (ACA). ACA requires non-grandfathered group health plans to comply with a maximum annual limitation on enrollee 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 2026 is $10,150 for self-only coverage and $20,300 for family coverage. Additionally, the 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. The limits for 2026 represent a significant increase—approximately 10.3%—from the 2025 limits of $9,200 for self-only coverage and $18,400 for family coverage.
All 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. 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.
HSA-Compatible High Deductible Health Plans
Employers offering high deductible health plans (HDHPs) paired with a health savings account (HSA) must comply with IRS requirements on cost sharing for HSA plans. These requirements encompass a minimum deductible, a maximum out-of-pocket limit and a maximum HSA contribution amount. The HSA plan 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 the spring of 2025 for plan years beginning in 2026.
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 adviser for insurance-related questions.
Authored by
Holly Wahl
EB Compliance Practice Leader
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.
