Out-of-pocket maximum/limit

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn't include:

  • Your monthly premiums
  • Anything you spend for services your plan doesn't cover
  • Out-of-network care and services
  • Costs above the allowed amount for a service that a provider may charge

The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.

  • For the 2020 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,150 for an individual and $16,300 for a family.
  • For the 2019 plan year: The out-of-pocket limit for a Marketplace plan couldn’t be more than $7,900 for an individual and $15,800 for a family.

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