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What is an out-of-pocket limit?

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.


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