The three agencies responsible for the implementation of health care reform (Treasury, Health and Human Services, and Labor) released a joint set of Frequently Asked Questions on cost sharing limits.

Health care reform places a limit on the dollar amount of out-of-pocket expenses that a participant may be charged in a year. In 2014, that limit is $6,350 for self-only coverage and $12,700 for other coverage. In 2015, the limit increases to $6,600 for self-only coverage and $13,200 for other coverage.

The guidance clarifies that if an out-of-network provider charges an amount greater than the amount allowed by the plan (i.e., balance bills the amount above the usual and customary charge), the plan may, but is not required to, consider this amount toward the out-of-pocket limit.

When a plan has reference-based pricing and pays a fixed amount for a procedure, the guidance provides that the plan may consider the out-of-pocket costs incurred when a provider does not accept the coverage amount as payment in full as part of the out-of-pocket maximum.

The FAQs also address how to treat an individual’s out-of-pocket costs for a brand-name prescription drug when a generic is available and medically appropriate.

The new FAQs offer useful guidance for plans in administering out-of-pocket limitations on plan benefits