60.6%
increase in the federal limit on out-of-pocket costs for single coverage, 2015 to 2026
Source: KFF 2015 Employer Health Benefits Survey and KFF 2026 Employer Health Benefits Survey.
Medical Balance Protection™, also known as Gap coverage. Not to be confused with what is on your automobile.
This is not the same as balance billing protection under the No Surprises Act.
The federal No Surprises Act protects patients from unexpected charges when they receive care from an out-of-network provider. Medical Balance Protection™ is something different entirely.
A separate, optional insurance product offered alongside an employer's existing group health insurance and employee benefits, designed to pay toward the balance an employee still owes after their group health plan pays its share.
What it actually is
Medical Balance Protection™ is one of four pillars used to build a complete benefits strategy, alongside group health insurance, wellness, and voluntary benefits.
It is a separate policy. Not a replacement for group health coverage. It works alongside whatever group coverage an employer already offers.
Different animals, different needs. Same with your workforce.
How it works in practice
- 1. An employee visits the doctor or is treated at a hospital.
- 2. The provider bills the insurance company.
- 3. The insurance company reprices the claim based on the plan's negotiated rates.
- 4. The repriced claim is returned to the provider, showing what the plan will cover and what remains.
- 5. The provider then bills Medical Balance Protection™ for some or all of that remaining balance.
- 6. Payment goes directly to the provider. Not to the employee.
- 7. Medical Balance Protection™ pays 100 percent of cancer treatment, hospital stays, and delivery room charges. For all other services, such as lab work and imaging, it pays 50 percent. The employee is responsible for the remaining balance.
Why it exists
Group health insurance covers a large share of a serious medical event. Rarely all of it.
The maximum an employee could owe out of pocket has climbed sharply over the past decade. The federal cap alone rose from $6,600 in 2015 to $10,600 in 2026, a 60.6 percent increase. (Source: calculated from KFF-reported ACA limits: KFF 2015 Employer Health Benefits Survey and KFF 2026 Employer Health Benefits Survey.)
Real small business plans typically set individual out-of-pocket maximums between $5,500 and $7,500. Still a significant amount for a family already managing a medical crisis.
Medical Balance Protection™ exists to close that specific gap: the space between what group health pays, and what an employee would otherwise owe.
Why it matters
The Story of John
Years ago, a friend's husband ended up in the emergency room for what looked like a burst appendix. During surgery, doctors found something else. Cancer.
He is healthy today. But because his employer changed insurance carriers partway through the year without reviewing the plan carefully, his family hit their maximum out-of-pocket three separate times in eight months.
They were fortunate enough to absorb it through savings. Many families would not have that option. In 2026, 47% of employees said they could not cover $1,000 in out-of-pocket costs from a medical event.
Source: Aflac 2026-2027 WorkForces Report, October 2026
Medical Balance Protection™ is optional, and employers can choose not to include it. These are the reasons it is recommended as part of EVERY benefits strategy built through AgentDavidCares.com.
A real example, 20 employees
What it looks like in practice
A 20-employee employer was paying $16,000 a month for a traditional fully insured gold plan. I moved them to a level-funded bronze plan, the group was healthy enough to qualify, and added Medical Balance Protection™.
The out-of-pocket went from $2,500 to $7,500 on paper. Medical Balance Protection™ stepped in to cover the employee's portion of that maximum out of pocket, paying 100% of hospital, cancer, and pregnancy related costs and 50% of lab and imaging costs.
Total cost dropped from $16,000 to $8,000 a month: $400 per employee per month instead of $800, split 50/50 between employer and employee. Everybody ended up with extra money in their pocket.
A real example, the delivery room
Two weeks in, it proved itself
Fall 2021. A gym owner in Tennessee carried level-funded coverage with Medical Balance Protection™. His wife, a local school district teacher, moved onto his plan at the last minute, November 1. Two weeks later she delivered a healthy baby girl.
Most health insurance covers the doctor visits, the medicine, the vitamins, but the delivery room lands on the family. On the school district plan, it would have been on them. Medical Balance Protection™ picked it up. Two weeks in, it proved itself.
Questions employees ask
Does it pay the hospital, or reimburse the employee?
It pays the provider directly toward the remaining medical balance. The employee does not have to file paperwork and wait for reimbursement.
Is Medical Balance Protection™ the same as balance billing protection under the No Surprises Act?
No. The No Surprises Act is a federal law protecting patients from unexpected out-of-network charges. Medical Balance Protection™ is a separate, optional insurance product that pays toward an employee's remaining balance after group health insurance pays its share, regardless of network status.
Does Medical Balance Protection™ replace group health insurance?
No. It is a separate policy that works alongside an employer's existing group health insurance, not a substitute for it.
Who receives the payment when a claim is filed?
Medical Balance Protection™ pays directly to the medical provider, not the employee. The provider is then responsible for billing any remaining balance, if any, directly.
Is this available to any employer?
It is offered as part of a complete benefits strategy for employers who already provide group health insurance. Contact AgentDavidCares.com to see if it fits your group.
Is Medical Balance Protection™ required?
No. It is optional, and employers can choose not to include it as part of their overall benefits strategy.
A high deductible does not have to mean a bill your employee cannot pay.
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