Your costs that contribute to your out-of-pocket maximum limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.
For 2016, the maximum out-of-pocket expenses for individual plans for in-network services are:
- Individuals: $6,850 Out-of-Pocket Maximum
- Family: $13,700 Out-of-Pocket Maximum
Like the deductible, the out-of-pocket maximum applies to the calendar year (January 1st - December 31st) and is not prorated if your plan starts in the middle of the year or if you change plans during the Special Enrollment Period.