Out of Pocket Maximum for Health Insurance

All health insurance policies must follow guidelines under the Affordable Care Act.

One guideline is the out of pocket maximum (OOPM). The OOPM is the most an insured can pay out of their pocket in one year. Also can be referred to as cost sharing.

For 2016, the OOPM cannot exceed $6,850 for a single and $13,700 for a family. This is the OOPM for in network services.  Out of network OOPM is significantly more, that is assuming your policy has out of network coverage. A lot of policies today, do not have coverage for out of network.

$6,850 is a significant amount of money to pay out of pocket for most Hoosier and US citizens/legal residents.

For a middle class family of 4, that does not qualify for tax credits and does not have access to group coverage.   Here in Indiana, let’s assume they elect a plan a bronze plan off the exchange.

Monthly premium is $918 x 12= $11,016 a year.

OOPM = $13,700 a year.

In a bad year, this middle class family could have a total cost $24,716.

An average Indiana family = $15,016 with premium and medical claims. This would be the savvy healthcare consumer that uses RX coupons and shops healthcare services.

For 2017:

Individual OOPM increase of $300 to $7,150

Family OOPM increase of $600 to $14,300

The OOPM under the ACA is absolutely getting unaffordable.

Even families that are eligible for tax credits, with reduced premiums, $7,150 is completely unaffordable!

$14,300 OOPM is well beyond affordability.

As an insurance brokerage, we are trying to address these OOPM for our clients. (Individual and Group Coverage)

One of the strategies we have used with group health plans is introductions of supplemental policies. These policies will help to offset the OOPM. We are now forced to find similar options in the individual health market. We now have to purchase additional insurance with our insurance to offset financial hardship. ACA is quickly becoming unaffordable to all.

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