ERIC Urges Greater Flexibility and Clarity for ACA Out-of-Pocket Rules

For Immediate Release

Washington, DC – The ERISA Industry Committee (ERIC) has written to the Departments of Health and Human Services, Labor, and Treasury urging the agencies to provide greater flexibility and clarity with respect to the out-of-pockets rules under the Affordable Care Act (ACA). 

ERIC recommends, among other things, that the Departments clarify that the cost-sharing limits are applied only to those benefits that large employers have determined to be essential health benefits.  This approach would be consistent with application of the limits on annual and lifetime maximums to essential health benefits.

The Departments were also encouraged to issue guidance that permits an employer to apply the out-of-pocket limits only to the employer’s lowest cost coverage option.  Noting that group health plans frequently provide participants with several different options, ERIC explains that this approach would allow participants to choose the option that is best suited for their needs.

ERIC further recommends that the cost-sharing limits should not apply to the additional charges that arise from a participant’s failure to use a plan’s cost management methods.  For example, some plans require participants to use genERIC drugs when available, or pay more for higher-cost brand-name prescription drugs.  These higher costs should not be subject to the limit on cost-sharing. 

The FAQs About Affordable Care Act Implementation (Part XII) issued by the Departments included a transition rule beginning in 2014 for certain plans that use more than one service provider to administer benefits. ERIC also requested that the transition rule be applicable to other instances where coordination among service providers is required and, further, that the rule itself be extended for an additional two years. 

Finally, the letter encourages the Departments to retain the rule provided in the FAQs limiting the amount of deductibles only for health plans offered in the small group market. 

ERIC Comment Letter on Out-of-Pocket Rules


All media inquiries to The ERISA Industry Committee should be directed to:

Kelly Broadway, 202.627.1918,

About the ERISA Industry Committee
ERIC helps America’s largest employers stay ahead of employee benefit policy. ERIC member companies are leaders in every sector of the economy, and we represent them in their capacity as sponsors of employee benefit plans for their own workforce. Only ERIC provides the combination of intel, expertise, collaboration, and lobbying that exclusively serves the interests of large employers who provide health, retirement, and compensation benefits to their nationwide workforce.