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.
2025 out-of-pocket limits
As of January 1, 2025, non-qualified high deductible health (non-HSA) plans must cap in-network out-of-pocket expenses at:
- $9,200 individual
- $18,400 family
For qualified high deductible health plans, which can be paired with a health savings account, the out-of-pocket limit is:
- $8,300 individual
- $16,600 family
The minimum deductible is:
- $1,650 individual
- $3,300 family
The maximum contribution is:
- $4,300 individual
- $8,550 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 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.
