The maximum out-of-pocket (MOOP) provision requires that plans include a limit on
the amount of money customers spend out of pocket on health services in a given
year. This applies to all non-grandfathered, individual, small group, and large group
customers, whether they are fully-insured or self-funded. Grandfathered plans are not
subject to this provision.

All in-network out-of-pocket amounts (i.e., deductible, copayments, and coinsurance)
from all third-party administrators will accumulate to the annual out-of-pocket
maximum. Please note, the limit does not apply to out-of-network services.

The MOOP for 2021 for self-only coverage is $8,550 and $17,100 for family. The
MOOP for 2022 is $8,700 for self-only coverage and $17,400 for family.

The HSA compatible HDHP limits will continue to be lower than non-HDHP plans.
HDHPs are tied to the CPI, where non-HDHP plans are tied to average premium
increases. HHS allowed each state to tailor the minimum essential benefit provision to
their own state experience.

States chose their own benchmark plan from four benchmark plan types:

  • The largest plan by enrollment in any of the three largest small group insurance
    produces in the state;
  • Any of the largest three state employee benefit plans;
  • Nny of the largest three national Federal Employee Health Benefits Program (FEHBP) plans; or
  • The largest commercial HMO in the state.