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out-of-pocket maximum

What is an out-of-pocket maximum?

A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual’s health care expenses.

For 2016, the maximum out-of-pocket (for in-network care that’s considered an essential health benefit) was $6,850 for an individual, and $13,700 for a family. There’s also a requirement starting in 2016 that individual maximum out-of-pocket limits be embedded in family plans. Note that all of this applies to plans that are not grandfathered or grandmothered, as those plans do not have restrictions on their out-of-pocket exposure.

For 2017, the maximum out-of-pocket limit is $7,150 for an individual, and $14,300 for a family.

For 2018, the maximum out-of-pocket limit will be $7,350 for an individual, and $14,700 for a family. In any year, plans can have out-of-pocket limits below the established thresholds, however.