Groups Fear Workers May Get Large Out-of-Pocket Health Costs Next Year

Consumer groups are warning that insurers and employers may be able to keep offering health plans next year that include out-of-pocket caps for individuals of $12,500 or more — double the amount allowed under the federal health law.

The Obama administration has decided not to enforce that section of the law for some plans for another year, say 10 consumer groups which Monday wrote federal officials asking that the move be reconsidered.

“This is a very important consumer protection that is being undermined,” said Stephen Finan, policy director for the American Cancer Society Cancer Action Network, one of the groups that signed the protest letter. “Someone with a high drug bill could have out-of-pocket costs well in excess of the law.”

Getting hit by multiple caps

Under the federal law, starting Jan. 1 health plans must include certain benefits, such as hospital care and drug coverage, and must cap the amount consumers can be charged through deductibles, co-payments and co-insurance. That out-of-pocket cap next year is estimated to be about $6,250 for an individual.

But in a Feb. 20 FAQ put out by the U.S. Departments of Labor, Treasury and Health and Human Services, the administration noted that some insurance plans offered by employers have separate policies or benefit managers for different parts of their coverage, such as medical care and drugs, and sometimes a third for children’s dental services. Some employer plans have separate out-of-pocket caps for each of the coverage areas.

Because of the complexity, the FAQ gave insurers and employers another year to find ways to merge those caps. In theory, that means some plans next year may be able to double – or even triple – the $6,250 out-of-pocket cap, said the consumer groups. Plans with only one administrator overseeing all types of coverage are not exempted from the spending cap.

Finan said it is not known how many insurance plans offered by employers have multiple administrators, but it is thought to be fairly common.

He said administration officials indicated they allowed the one-year delay of the cap because “they got considerable feedback from health plans and employers that they could not comply or do the changes to develop a single out-of-pocket limit.”

Labor Department “is not going to enforce the law”

Administration officials were not immediately available for comment.

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The consumer groups say technology exists that could simply combine the separate administrative functions to create a single out-of-pocket cap, eliminating the need for the extension. Failing that, the groups asked the federal officials to simply divide the total amount of the cop among the different administrators, so that consumers do not face higher limits than allowed under the law.

“The FAQ does not have the force of law, but what it simply says is the Department of Labor is not going to enforce the law,” said Finan, who added that the groups had been in talks with administration officials on the issue since February.

He said the groups were especially concerned after learning from the administration that some drug plans have no out-of-pocket maximums and will not be required to set one next year.

Other signatories of the letter sent to the Departments of Labor, Treasury and Health and Human Services include AARP, the American Heart Association and Consumers Union.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Julie Appleby reports on the implementation of the health care overhaul law, the interplay of health care treatments and costs, trends in health insurance, and policy issues affecting hospitals and other medical providers, for Kaiser Health News. Contact her at