Out-of-pocket Maximum Limits on Health Plans

what is out of pocket in health insurance

The ACA limits out-of-pocket maximums, the max amount of costs for covered services you’ll pay out-of-pocket in a policy period on your health plan. In 2015, your out-of-pocket maximum can be no more than $6,600 for an individual plan and $13,200 for a family plan before marketplace subsidies.

What is an Out-of-pocket Maximum?

An out-of-pocket maximum is the total amount you’ll have to pay during a policy period, typically a year, before your health insurance starts to pay 100% for covered essential health benefits .

What Costs Count Toward my Out-of-pocket Maximum

Your costs that contribute to your out-of-pocket maximum limit must include deductibles. coinsurance. copayments. or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums. balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits .

Avoiding Confusion

Out-of-pocket maximums only apply to covered essential benefits.  So if your plan doesn’t cover a service, or the service isn’t an essential benefit it may not count toward your maximum.

Out-of-pocket maximums should not be confused with deductibles (the amount you pay out-of-pocket before coinsurance kicks in). That being said, on some high deductible health plans like catastrophic coverage your maximum will be the same as your deductible.

Out-of-pocket Maximums and ObamaCare

Before the ACA there was a lot more leeway for insurers to tweak how they treated out-of-pocket maximums. Even though things are a lot simpler now, depending on your plan not all services are going to be covered 100% and not

all services are always going to count toward your out-of-pocket maximum. Double check that your health plan isn’t cutting any of the corners found at this great article from about.com .

Out-of-pocket Maximums and Subsidies

Under the ACA if you make less than 250% of the Federal Poverty Level (FPL) you may qualify for Cost Sharing Reduction Subsidies. These subsidies reduce the out-of-pocket costs you are responsible for and reduce your out-of-pocket maximum as well.

For 2015 subsidies, if your income is:

  • 100-200 percent of FPL,
    • your out-of-pocket limit won’t be more than $2,250 for an individual.
    • your out-of-pocket limit won’t be more than $4,500 for a family.
  • 200-250 percent of FPL,
    • your out-of-pocket limit won’t be more than $5,200 for an individual.
    • your out-of-pocket limit won’t be more than $10,400 for a family.
  • More than 250% percent of FPL,
    • your out-of-pocket limit won’t be more than $6,600 for an individual.
    • your out-of-pocket limit won’t be more than $13,200 for a family.

What Are Essential Health Benefits?

In general Essential Health Benefits are the types of care you need to prevent and treat sickness and do not include elective and “non-essential treatments”. All private plans sold on the individual market must cover services from each of the ten following essential health benefit categories.

• Emergency services

• Hospitalizations

• Laboratory services

• Maternity care

• Mental health and substance abuse treatment

• Outpatient, or ambulatory care

Source: obamacarefacts.com

Category: Insurance

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