The Department of Health and Human Services (HHS) has released its final regulations under the Affordable Care Act (ACA) Marketplace Integrity and Affordability rule, bringing important updates for employers, plan sponsors, and individuals. While these regulations primarily impact Marketplace coverage, they include a notable revision to out-of-pocket maximum (OOPM) limits for plan years beginning on or after January 1, 2026.
Updated 2026 Out-of-Pocket Maximums
The newly finalized limits reflect an updated calculation methodology designed to better align with premium growth trends. The revised maximums are:
- $10,600 for self-only coverage (up from $10,150)
- $21,200 for other-than-self-only coverage (up from $20,300)
These amounts apply to non-grandfathered group medical plans, but it is essential to note that limits differ for HSA-compatible high-deductible health plans (HDHPs).
2026 HDHP Out-of-Pocket Maximums:
- $8,500 for self-only coverage (up from $8,300 in 2025)
- $17,000 for other-than-self-only coverage (up from $16,600 in 2025)
Employers offering HDHPs should carefully verify that their plan designs remain compliant with both ACA and HSA eligibility requirements.
Additional Rule Highlights
The finalized rule also clarifies coverage of specified sex-trait modification procedures for carriers subject to essential health benefit (EHB) requirements:
- These procedures cannot be classified as an EHB under federal rules.
- Carriers may voluntarily offer coverage, and states may require it, provided they follow state-mandated benefit rules.
This update primarily impacts non-grandfathered individual and small group health plans subject to EHB standards.
Employer Action Steps
Employers and plan administrators should take the following actions to remain compliant:
- Review 2026 plan designs to ensure OOPM limits do not exceed the newly finalized amounts.
- Confirm HDHP compliance for plans paired with HSA contributions.
- Stay informed on state-level mandates if offering coverage in multiple jurisdictions.
By proactively adjusting plan designs now, employers can avoid compliance risks and maintain ACA adherence heading into the 2026 plan year.
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