The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.


How Are Your Administrators Complying With the ACA Maximum Out-of-Pocket Limits that Started January 1?

Tuesday, February 23, 2016

According to a , beginning in 2016, the Affordable Care Act (ACA) limits how much people have to pay out of pocket for deductibles, coinsurance and copayments across all benefit types. The maximum yearly amount is $6,850 for individuals, and $13,700 for families.

This new requirement means that your medical, mental health, and prescription drug administrators have to start sharing data to ensure your plan members don’t pay more than the maximum out-of-pocket limit across all benefit types combined. 

It’s Complicated, but Doesn’t Have to Be.

Truven Health Analytics research finds that cross-administrator integration often isn’t implemented properly. Ensure your administrators are meeting the above, and other complex requirements, with a 100 percent, post-implementation audit approximately 90 days after the date of your material change. This analysis should:

  • Re-adjudicate all claims for compliance with plan designs
  • Validate eligibility and compliance with your administrator’s policies and procedures
  • Incorporate industry best practices
  • Flag areas where you’re not, or are at risk of not, meeting ACA regulations

If you’ve recently made plan design or administrator changes, to explore what our audits uncovered for some clients – and could uncover for you.

Marie Bowker
Senior Director, Payment Integrity


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