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Good to Know: Annual Cost-Sharing Limits, Excise Tax, Guaranteed Issue

Annual cost-sharing limits

Annual cost-sharing limits are limits on how much people have to spend on their own health care. The annual cost-sharing — or out-of-pocket (OOP) expenses — is $6,850 for self-only and $13,700 for family coverage.

The limitation and cross-accumulation of cost-sharing applies to all covered plan services, including non-Essential Health Benefits and ancillary benefits. Transitional relief allows implementation to happen in two phases. 

All medical services cross-accumulate to this annual cost-sharing limit. However, cross-accumulation to benefits administered by third-party service providers may be delayed until 2015.

Health Net will delay cross-accumulation with pharmacy benefits for our nongrandfathered large group plans. This means that OOP limits for medical and for pharmacy benefits will be separate in 2014.

In addition, for nongrandfathered small group plans, the annual deductible may not exceed $2,000 for individual coverage or $4,000 for family coverage (certain exceptions apply).

Excise tax

Scheduled to take effect in 2018, the excise tax is a 40 percent tax on employer-sponsored group health plans with costs that exceed a predetermined level. The cost level (as of July 2013) is $10,200 for individual coverage and $27,500 for family coverage.

More information on the excise tax aka "Cadillac Tax"

Guaranteed availability of insurance 

Health insurance issuers must accept all individuals in the state that apply for coverage regardless of health, age, gender, or any other factors including pre-existing conditions.