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.

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 was 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 was $7,150 for an individual, and $14,300 for a family.

For 2018, the maximum out-of-pocket limit is $7,350 for an individual, and $14,700 for a family.

For 2019, the maximum out-of-pocket limit will be $7,900 for an individual, and $15,800 for a family. In any year, plans can have out-of-pocket limits below the established thresholds, however.