ACA’s Cost-sharing Limit and No Surprises Act FAQs

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Frequently asked questions were recently issued regarding the Affordable Care Act’s (ACA) overall cost-sharing limit and the No Surprises Act’s (NSA) protections against surprise medical billing.

Cost-sharing Limit and NSA Protections

The NSA will provide federal protections against balance billing and out-of-network cost sharing for a variety of services. It’s effective for plan years beginning on or after January 1, 2022.

Non-grandfathered health plans must ensure that an enrollee’s cost sharing for essential benefits doesn’t exceed the maximum out-of-pocket (MOOP) limit. For 2023, the MOOP limit is $9,100 for self-only coverage and $18,200 for family. For 2023, self-only coverage is $9,450 and $18,900 for family.

FAQs

The FAQs provide guidance regarding the NSA’s protections and the ACA’s MOOP limit.

• Cost sharing for services provided by a nonparticipating provider are considered out-of-network for purposes of the MOOP limit; and
• Health care providers or facilities that have a contractual relationship with a plan or issuer are considered in-network for purposes of the ACA’s MOOP limit.

In addition, the Transparency in Coverage final rule requires health plans and issuers to make price comparison information available to participants through an internet-based service tool and in paper form upon request. The price comparison piece must include facility fees that are increasingly being charged for health care received outside of hospital settings. This information must be available beginning January 1, 2023, with respect to 500 items and services as well as all covered items and services, beginning on January 1, 2024.

For more information, download the bulletin.