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Open Enrollment

Do you know about out-of-pocket limits?

Oct 05 2016

Even if you have a high-deductible health insurance plan, there is a limit on the total you have to spend out-of-pocket over the course of the year.

First, a quick explanation of out-of-pocket maximums.

Almost all health plans today offer members the protection of an out-of-pocket maximum. That’s the most an individual member or a family will have to pay out of their pocket in a year in deductibles and coinsurance or copays. Specifically, the maximum applies to care you get in the health plan’s network for what’s considered Essential Health Benefits. After that maximum is hit, the health plan pays the allowed amount for all covered services in-network.

The government sets a limit on how much these maximums can be. Family health plans can have a single out-of-pocket maximum for the family. Family maximums can be twice as high as the maximum amount in a plan covering just one person (a “self-only plan”). For 2017, the self-only maximum can be up to $7,150 and the family maximum, up to $14,300. For high-deductible plans that are compatible with Health Savings Accounts they are lower, up to $6,550 and $13,100.

The limit

The 2017 out-of-pocket maximums. For self-only plans, the maximum is $7,150. For families, the maximum is $14,300. For high-deductible plans, compatible with a Health Savings Account, the self-only maximum is $6,550 and $13,100 for families.No matter whether a plan covers just you (self-only) or you and a spouse or you and your kids, or your spouse AND kids, there is a limit on how much one person can be required to spend. Plans can’t require any one person to pay more than the maximum amount for self-only coverage.

So in a family health plan, if one family member’s covered bills hit the self-only limit, the plan must cover that person’s allowed bills in full for the rest of the year. The other family members will continue to pay deductibles and coinsurance or copays until one of them also reaches the self-only maximum, or the family maximum is reached.

Family plans can be set up one of two ways:

  • With a family maximum that is no more than the maximum for self-only coverage
  • With a higher family maximum but with an individual maximum “embedded” in the plan too. Once one person’s allowed bills reach the self-only maximum, his or her allowed bills are covered in full for the rest of the year. Other family members will continue to pay their share of their bills until one of them also reaches the self-only maximum, or the family maximum is reached.

Note: this information is not meant as legal advice. Please talk to your legal advisor about any questions.