maximum out of pocket

Maximum Out-of-Pocket Health Plan Limits for 2022

ACA Maximum Out-of-Pocket Limit for 2022

A plan’s out-of-pocket maximum (also called maximum out-of-pocket or MOOP) is the total amount that the patient would have to pay in a given year for in-network treatment classified as essential health benefits.

For 2022 Marketplace health coverage, the maximum out-of-pocket limit is $8,700 for a single person and $17,400 for a family. [Department of Health and Human Services].

Although the out-of-pocket limits apply to most health plans, they do not apply to grandfathered plans or “excepted benefits” such as short-term health plans and fixed indemnity plans. There is also no out-of-pocket cap on Original Medicare (Parts A and B), which is why most enrollees have Medicare supplemental coverage (from an employer-sponsored plan, Medigap, or Medicaid).

There will be many 2022 health plans with out-of-pocket limits well below $8,700 for a single person. This will include employer-sponsored and individual/family health plans at the silver, gold, and platinum levels. But all catastrophic plans for 2022 will have individual out-of-pocket limits of $8,700. And many bronze plans will also use this upper cap as their out-of-pocket maximum.

Note that the maximum out-of-pocket limits are lower for people who qualify for cost-sharing reductions (CSR). An applicant can receive CSR benefits if their household income is no more than 250% of the poverty level and they select a silver plan in the exchange.

According to Centers for Medicare & Medicaid Services (CMS), the maximum out-of-pocket limits depend on the person’s household income and have been set at these levels for 2022:

  • Income between 100% and 200% of the poverty level: $2,900 for a single person and $5,800 for family coverage
  • Income above 200% but not more than 250% of the poverty level: $6,950 for a single person and $13,900 for family coverage

What happens after your out-of-pocket maximum is met?

The out-of-pocket maximum is the most you’ll pay in a plan year. Once you reach your out-of-pocket max, your plan pays 100 percent of the allowed amount for covered services.

Speak With a Licensed Insurance Agent

The type of plan you purchase can determine the amount of out-of-pocket maximum vs. deductible costs you will incur. I can help you find the right health insurance plan for your budget and medical needs. Call me at (912) 660-5236 or go online to start comparing plans today.