Health insurance plans that meet the Affordable Care Act (ACA) standards must provide out-of-pocket maximums for their customers. This includes most major insurance policies. On the other hand, there are some exceptions, such as short-term health plans, health-sharing ministry programs, and other grandfathered, non-ACA compliant plans.
While health insurance companies can set their own maximums, the ACA mandates that most plans have limits on what they can charge. For example, the out-of-pocket maximum limit for 2025 is:
- $9,200 for an individual
- $18,400 for a family
Different types of plans also offer different out-of-pocket maximum options.
Individual Plan
With an individual plan, only one person is on the policy. When that individual reaches their out-of-pocket maximum, the insurer will start paying 100 percent of their covered medical costs for the rest of the year.
Family Plan
Family plans are an option if you have a spouse or children. Within a family plan, you may have two types of out-of-pocket maximums:
- Individual Maximum Each person in the family has their own max to hit. Once they reach this amount, the insurer will pay all of that individual’s bills.
- Family Maximum The entire family’s expenses count toward the max. If one person in the family reaches the out-of-pocket maximum, the entire family will be covered for the rest of the year.
HMO vs. PPO
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