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The maximum out-of-pocket limitation (MOOP) will rise by 10 percent in 2026 for most commercial health plans, according to newly finalized cost sharing calculations from the Centers for Medicare & Medicaid Services (CMS). The federal limit applies to in-network essential health benefit cost sharing in non-grandfathered individual and group health plans, including self-insured employer plans. The federal MOOP limit increases in proportion to premium increases in the employer market. CMS has said it intends to propose a rule, with the Departments of Labor and the Treasury, that would require all covered drugs in group health plans to be considered essential health benefits that are subject to the MOOP, replacing the current policy that permits some plans to exclude some drugs from the limit on cost sharing. Plans can elect to have out-of-pocket limits that are lower than the federal maximum.
CMS also released the 2026 Draft Letter to Issuers in the Federally-facilitated Exchanges to give technical and operational direction to Marketplaces using the federal platform, following the October 4 release of the Notice of Benefit and Payment Parameters (NBPP) proposed rule.
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