MOOP Drama

This article touches on spending within a family plan. While the author fails to specify, it’s assumed that the intended context is a self-funded environment.  Out of pocket maximums are complicated, and the rules are changing all the time, such as today with embedded MOOP rulings. Take the following scenario for example:

-You end up in the hospital with a plan covering 80% of your bill

-So, with $50,000 in hospital bills, your insurance will leave you with 20% out of pocket, or $10,000

-If as an individual, your Maximum Out Of Pocket (or MOOP) is $6,000, that’s all you pay of that $10 grand

-With a family plan at $12,000 MOOP, you’d have to pay the full $10,000, right?


The plan says $6,000 MOOP per individual. That means every individual, even within family plans. So whether you have a family or individual plan, you pay the individual out of pocket rate for your company’s plan.

However, this can add strain to an employer who anticipated that the employee would be covering a significantly bigger chunk of their medical bills. The employer may now be paying an unexpected $4k to finish off this example employee’s $10,000 bill.

All of this might already make sense to you, but the federal government just released a “clarification” to confirm and require all of the aforementioned practices. If you weren’t already aware of them, heads up.