HHS Revises Cost-Sharing Limits For 2026 Plan Years

On June 25, the U.S. Department of Health and Human Services (HHS) published a final rule to implement new standards for the Affordable Care Act’s (ACA) Marketplaces. This final rule also updates the methodology used for calculating the A CA’s maximum annual limitation on cost sharing. Based on this update, the maximum annual limitation on cost sharing is $10,600 for self-only coverage and $21,200 for family coverage for 2026 plan years. This represents an approximately 15.2% increase from the 2025 limits of $9,200 for self-only coverage and $18,400 for family coverage.

HHS previously released the maximum limits on cost sharing for 2026 based on a now-outdated methodology. Those limits ($10,150 for self-only coverage and $20,300 for family coverage) have been replaced with the revised limits.

Out-of-Pocket Maximum

The ACA requires most health plans to comply with annual limits on total enrollee cost sharing for essential health benefits (EHBs). The ACA’s cost-sharing limits apply to all non-grandfathered health plans, including self-insured health plans, level-funded health plans, and fully insured health plans of any size.

These cost-sharing limits are commonly referred to as an out-of-pocket maximum. Once the out-of-pocket maximum is reached for the year, the enrollee cannot be responsible for additional cost sharing for EHBs for the remainder of the year.

Under the ACA, EHBs must reflect the scope of benefits covered by a typical employer plan and include items and services in 10 general categories, including emergency services, hospitalization, prescription drugs, pediatric services, outpatient care, and maternity and newborn care.

Any out-of-pocket expenses required by or on behalf of an enrollee with respect to EHBs must count toward the cost-sharing limit. This includes deductibles, copayments, coinsurance, and similar charges, but excludes premiums and spending for non-covered services. Health plans that use provider networks are not required to count an enrollee’s expenses for out-of-network benefits toward the cost-sharing limit.

Also, the ACA requires health plans to apply an embedded out-of-pocket limit for everyone enrolled in coverage. Each enrollee must have an individual out-of-pocket limit on EHBs that is not higher than the ACA’s out-of-pocket maximum for self-only coverage.

Annual Limits

The ACA’s cost-sharing limit is adjusted each year for inflation. For plan years beginning in 2025, the out-of-pocket maximum is $9,200 for self-only coverage and $18,400 for family coverage. For plan years beginning in 2026, the limits are $10,600 and $21,200, respectively. Employers should review the plan designs each year to ensure they comply with the ACA’s cost-sharing limits.

For more information or for assistance with your employee benefit plan designs to ensure compliance, email The Siekmann Company.

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This Legal Update is not intended to be exhaustive, nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.