Out-of-Pocket Maximums Under the Affordable Care Act

The ACA limits out-of-pocket maximums, the max amount of costs for covered services you’ll pay out-of-pocket in a policy period on your health plan.

  • For 2022, your out-of-pocket maximum can be no more than $8,700 for an individual plan and $17,400 for a family plan before marketplace subsidies. These numbers have been revised up for 2022, they were slightly lower, $8,550 and $17,100 respectively in 2021.
  • For 2022, your maximum deductible is the same as the out-of-pocket maximum.

TIP: See Notice of Benefit and Payment Parameters for 2022 for final levels.

NOTE: The individual limit applies to each individual in the plan. Thus, for 2022, even though the family limit is $17,400, no one member can occur more than $8,700 in covered expenses before the maximum is reached for that member.

Out-of-pocket maximums increase a little each year. For example:

  • In 2015, your out-of-pocket maximum could be no more than $6,600 for an individual plan and $13,200 for a family plan before marketplace subsidies.
  • In 2016, your out-of-pocket maximum could be no more than $6,850 for an individual plan and $13,700 for a family plan before marketplace subsidies.
  • In 2017, your out-of-pocket maximum could be no more than $7,150 for an individual plan and $14,300 for a family plan before marketplace subsidies.
  • In 2018, your out-of-pocket maximum could be no more than $7,350 for an individual plan and $14,700 for a family plan before marketplace subsidies.
  • For 2019, your out-of-pocket maximum can be no more than $7,900 for an individual plan and $15,800 for a family plan before marketplace subsidies.
  • For 2020, your out-of-pocket maximum can be no more than $8,150 for an individual plan and $16,300 for a family plan before marketplace subsidies.
  • For 2021, your out-of-pocket maximum can be no more than $8,550 for an individual plan and $17,100 for a family plan before marketplace subsidies.

Learn more about out-of-pocket maximums under the ACA below.

What is an Out-of-pocket Maximum?

An out-of-pocket maximum is the total amount you’ll have to pay during a policy period, typically a year, before your health insurance starts to pay 100% for covered essential health benefits.

What Costs Count Toward my Out-of-pocket Maximum

Your costs that contribute to your out-of-pocket maximum 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.

Avoiding Confusion

Out-of-pocket maximums only apply to covered essential benefits.  So if your plan doesn’t cover a service, or the service isn’t an essential benefit it may not count toward your maximum.

Out-of-pocket maximums should not be confused with deductibles (the amount you pay out-of-pocket before coinsurance kicks in). That being said, on some high deductible health plans like catastrophic coverage your maximum will be the same as your deductible.

Maximums and Deductibles on HSA-Eligible Plans in 2022

The maximum and deductible requirements for HSA qualifying plans are not the same as maximums and deductibles on health plans in general. Below are the HSA limits for 2022.

Minimum Deductible for HSA Eligibility 2022

  • $1,400 for self-only coverage (no change from 2021)
  • $2,800 for family coverage (no change from 2021)

NOTE: It is $2,800 for embedded individual deductible (no change from 2021)

NOTE: The minimum deductible, which is the minimum deductible your High Deductible Health Plan must have after cost assistance.

Maximum Out-of-Pocket Limit for HSA Eligibility 2022

  • $7,050 for self-only coverage ($50 increase from 2021)
  • $14,100 for family coverage ($100 increase from 2021)

NOTE: The maximum out-of-pocket is the highest maximum a plan can have to qualify for an HSA.

TIP: The maximums are slightly lower on HSA compatible plans than they are in general on health plans. This has to do with the fact that the rates are raised by different mechanisms. The difference allows for non-HSA compatible high deductible plans. Thus, if you want an HSA, make sure your plan is “HSA Eligible.”

HSA Contribution Limit for 2022

  • $3,650 for self-only coverage
  • $7,300 for family coverage

NOTE: 55 plus can contribute an extra $1,000.

TIP: See Revenue Procedure 2021-25 for final HSA levels.

TIP: Out-of-pocket maximum limits are higher than the limits for HSA eligibility. For 2019, your out-of-pocket maximum can be no more than $7,900 for an individual plan and $15,800 for a family plan before marketplace subsidies. This allows high deductible plans that aren’t HSA eligible! So, if you want an HSA, make sure you get a plan that meets the HSA eligibility criteria.

Out-of-pocket Maximums and ObamaCare

Before the ACA there was a lot more leeway for insurers to tweak how they treated out-of-pocket maximums. Even though things are a lot simpler now, depending on your plan, not all services are going to be covered 100% and not all services are always going to count toward your out-of-pocket maximum. Double-check that your health plan isn’t cutting any of the corners found at this great article from about.com.

Out-of-pocket Maximums and Subsidies

Under the ACA if you make less than 250% of the Federal Poverty Level (FPL) you may qualify for Cost Sharing Reduction Subsidies. These subsidies reduce the out-of-pocket costs you are responsible for and reduce your out-of-pocket maximum as well.

For example, let’s look at 2015 numbers to offer an idea of how these subsidies work (i.e. the numbers are just used as an example here). For 2015 subsidies (based on the Second Lowest Cost Silver plan in your marketplace), if your income was:

  • 100-200 percent of FPL,
    • your out-of-pocket limit won’t be more than $2,250 for an individual.
    • your out-of-pocket limit won’t be more than $4,500 for a family.
  • 200-250 percent of FPL,
    • your out-of-pocket limit won’t be more than $5,200 for an individual.
    • your out-of-pocket limit won’t be more than $10,400 for a family.
  • More than 250% percent of FPL,
    • your out-of-pocket limit won’t be more than $6,600 for an individual.
    • your out-of-pocket limit won’t be more than $13,200 for a family.

TIP: The method is the same every year, but the guidelines are adjusted upward slightly each year.

What Are Essential Health Benefits?

In general Essential Health Benefits are the types of care you need to prevent and treat sickness and do not include elective and “non-essential treatments”. All private plans sold on the individual market must cover services from each of the ten following essential health benefit categories.

• Emergency services
• Hospitalizations
• Laboratory services
• Maternity care
• Mental health and substance abuse treatment
• Outpatient, or ambulatory care
• Pediatric care
• Prescription drugs
• Preventive care
• Rehabilitative and rehabilitative (helping
maintain daily functioning) services
• Vision and dental care for children

See our full list of Essential Benefits under the Affordable Care Act with detailed descriptions.