Maximum Out-of-Pocket Limits Increase for 2019

The Department of Health and Human Services (HHS) issued final Benefit and Payment Parameters for 2019 that include increased Maximum Out-of-Pocket limits for Essential Health Benefits (EHB) for plan years beginning after December 31, 2018. The limits in the following chart are applicable for all non-grandfathered plans.

Maximum Out-of-Pocket Limits




Maximums In-Network Out-Of-Pocket on EHBs for non-grandfathered  health plans

Self Only


Self Only






Note plans with family Out-Of-Pocket (OOP) limits must apply the self-only limit for each person enrolled in family coverage. This means that once a person covered under a family plan reaches the self-only OOP maximum, then all expenses above the self-only limit for covered essential health benefits (EHBs) for that person must be reimbursed at 100%, even if the family OOP maximum has not been met.


The remainder of the final regulations focuses primarily on the individual and small group markets, providing greater flexibility for issuers and the Exchanges. The biggest impact the final regulations will have on employer-sponsored group health plans stems from the additional flexibility given to states in how they can select their essential health benefits (EHB) benchmark plans for plan years 2020 and beyond. Generally, states will have more choices with respect to benefits and affordable coverage and issuers may be permitted to substitute benefits across EHB categories. Essentially states will be permitted to select less valuable benchmark plans. We cannot project the full impact that this new flexibility will have on the large group health plan market until the states begin to create their new benchmark plans for 2020.

If you have any questions about these or other limits or about the impact on your plan, contact your Cheiron consultant.

Cheiron is an actuarial consulting firm that provides actuarial and consulting advice. However, we are neither attorneys nor accountants. Accordingly, we do not provide legal services or tax advice.