Out-of-pocket limit

The maximum amount members pay for covered health expenses

The Affordable Care Act’s out-of-pocket limit is the most a member will pay for the combined total of all copays, coinsurance and deductibles for covered services in a benefit period (usually a calendar year). Once the out-of-pocket limit is met, HAP pays the entire allowed amount for covered services for the rest of the benefit period.

Costs due to monthly premiums, non-covered prescriptions and non-covered medical services do not count toward the out-of-pocket limit.

2017 out-of-pocket limits

As of January 1, 2017, non-grandfathered health plans must cap in-network out-of-pocket expenses to:

• $7,150 individual
• $14,300 family

For qualified high deductible health plans, which can be paired with a health savings account, the out-of-pocket limit is:

• $6,550 individual
• $13,100 family

Pharmacy benefits

Most health insurance companies offer single-source policies that administer medical and pharmacy benefits. We give you the flexibility to make your own pharmacy benefit choices.

If you’re a large group with an existing HAP health plan, we’ll help you identify combined medical and pharmacy out-of-pocket limits. This will help your business comply with the 2017 combined limits under the ACA. Combined benefits don’t apply to qualified health plans.

Please be advised that HAP does not have access to the records of pharmacy benefit providers. We are able to monitor only out-of-pocket limits for medical services associated with health plans.