Out-of-Pocket Maximum Limit
Some insurance plans refer to the term as Out-of-Pocket Limit.
♦ The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered healthcare services.
The Affordable Care Act has provisions calling for standardizing these types of terms. The intent being to avoid confusion.
With the election of 2016, this effort at simplification has been pushed to the back burner.
♦ The Affordable Care Act controls the maximum out-of-pocket that insurance companies can ask for in-network services.
For the 2023 plan year, the out-of-pocket limit for a Marketplace plan is $9,100 for an individual plan and $18,200 for a family plan.
• This amount can be greatly reduced if you qualify for Cost-Sharing Reductions.