Healthcare

Out-of-pocket limits required for health insurance under Obamacare–stay in network

2014

The Affordable Care Act limits the annual amount individuals will pay out-of-pocket as a result of deductibles, co-insurance, and co-payments.

However, out-of-pocket costs from balance billing incurred through health care providers who are not network providers does not count toward the limit. Given many new plans have small networks of participating providers, or no out-of-network benefits at all, using only network providers is becoming more and more financially important.

The maximum out-of-pocket cost limit for any individual Marketplace plan for 2014 can be no more than $6,350 for an individual plan and $12,700 for a family plan. These limits are consistent with the limits for High Deductible Health Plans and HSAs. Grandfathered plans are excepted from these limits.

Here is what Healthcare.gov says

The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

Many consumers focus only on premiums. That is a mistake. To buy the best plan for you and your family you must estimate your likely health care use in a year and then balance premiums with deductibles, co-insurance, co-payments and limits on out-of pocket-costs.

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