out-of-pocket maximum

What is an out-of-pocket maximum?

An out-of-pocket maximum is a predetermined, limited amount of money that an individual must pay before an insurance company or (self-insured employer) will pay 100 percent of an individual’s health care expenses for the remainder of the year.

Health plans can set their own out-of-pocket maximums, but they’re constrained by federal regulations that impose an upper limit on how high out-of-pocket costs can be. In 2019, the upper limit is $7,900 for an individual, and $15,800 for a family. In 2020, it will be $8,150 for an individual and $16,300 for family coverage (these caps apply to in-network care that’s considered an essential health benefit, and only to plans that are not grandfathered or grandmothered, as those plans do not have restrictions on their out-of-pocket exposure.)

The federal government publishes new guidelines each year that include the highest out-of-pocket maximum that health plans can impose (the annual benefit and payment parameter notice). So the highest allowable out-of-pocket maximum changes annually. In 2014, it was just $6,300 for an individual, but by 2020, it will have increased by nearly 30 percent. Many health plans, however, have out-of-pocket maximums that are well below the highest allowable amounts.

For perspective, here are the federally-allowed maximum out-of-pocket amounts since they debuted:

  • 2014: $6,300 for an individual; $12,600 for a family
  • 2015: $6,600 for an individual; $13,200 for a family.
  • 2016: $6,850 for an individual; $13,700 for a family (there was also a requirement starting in 2016 that individual maximum out-of-pocket limits be embedded in family plans).
  • 2017: $7,150 for an individual; $14,300 for a family.
  • 2018: $7,350 for an individual; $14,700 for a family.
  • 2019: $7,900 for an individual; $15,800 for a family
  • 2020: $8,150 for an individual; $16,300 for a family.

If you have Medicare coverage, be aware that there is no out-of-pocket maximum for Original Medicare, which is why most enrollees have supplemental coverage (from an employer-sponsored plan, Medigap, or Medicaid). Medicare Advantage plans must cap out-of-pocket costs at no more than $6,700, but that does not include out-of-pocket costs for prescription drugs covered by the Part D coverage that’s integrated with most Advantage plans.

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