Help for those affected by the hurricanes | Learn More

A message from Aflac

To our policyholders in areas affected by the recent hurricanes, please know that the thoughts and prayers of everyone at Aflac are with you. We are working with government agencies that represent all declared disaster areas to ensure we do everything possible to help you. Based on that guidance, we have extended the due dates for policy premiums by 60 days for those living in places that have been declared disaster areas. If you have a question about your policy or need help, contact us at 800-992-3522. To help with the recovery, Aflac made a $500,000 donation to the American Red Cross, and our employees are making their own private contributions. Please be safe, as the care of you and your families is paramount.

Need-to-know details about out-of-pocket limits under the ACA

The Affordable Care Act (ACA) established out-of-pocket limits to protect consumers from runaway medical costs. The limits include essential health benefits covered under nongrandfathered plans, but out-of-network procedures or treatments not covered under an individual’s plan can still cost consumers more than the established limits. Here are the important details employers and employees need to know.

What are the out-of-pocket limits?

The limits reflect the most an individual or family will pay for covered essential health benefits before their plan begins to pay 100 percent of the costs. The limits are adjusted each year.

ACA compliant plans: Individual out-of-pocket maximum: $7,150, Family out-of-pocket maximum: $14,300. High-deductible health plans: Individual out-of-pocket maximum: $6,550, Family out-of-pocket maximum: $13,100.

What counts toward the out-of-pocket limit?

Covered essential health benefits are included in the out-of-pocket maximum. This includes deductibles, coinsurance, copayments or similar charges, and any other expenditure required of an individual that is a qualified medical expense for essential health benefits, which includes items and services in the following 10 categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Can actual out-of-pocket costs exceed these limits?

Yes. Out-of-pocket limits do not count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing or spending for nonessential health benefits. That means patients can rack up bills for procedures, treatments or prescriptions not covered under their plan or outside of their network. These costs won’t count toward their out-of-pocket limit but can directly affect their wallet.

How are limits applied to individuals who are part of a family plan?

Starting in 2016, the individual limit was extended to each member of a family plan. This means that an individual’s out-of-pocket expenses covered under their plan will not exceed the individual limit, and a family’s out-of-pocket expenses covered under their plan will not exceed the family out-of-pocket maximum when they are added together.

Example:
Consider Family A has an out-of-pocket maximum of $14,300 and their family members incur the following covered in-network and non-network out-of-pocket expenses:

Individual 1: (In-network covered cost-sharing expenses: Expenses: $10,000, Individual Responsibility: $7,150), Non-network expenses and nonessential health benefit costs: $2,000. Individual 2: (In-network covered cost-sharing expenses: Expenses: $3,000, Individual Responsibility: $3,000), Non-network expenses and nonessential health benefit costs: $500. Individual 3: (In-network covered cost-sharing expenses: Expenses: $3,000, Individual Responsibility: $3,000), Non-network expenses and nonessential health benefit costs: $500. Individual 4: (In-network covered cost-sharing expenses: Expenses: $3,000, Individual Responsibility: $3,000), Non-network expenses and nonessential health benefit costs: $500. Expenses Total: $19,000, Individual Responsibility Total: $16,150, Non-network expenses and nonessential health benefit costs Total: $3,500.

Individual 1’s out-of-pocket costs covered under their health insurance are capped at the individual maximum of $7,150. Even though family members 2, 3 and 4 don’t meet the individual out-of-pocket maximum by themselves, together the family’s out-of-pocket expenses for covered procedures and treatments would not exceed the family maximum of $14,300.

Total individual cost-sharing responsibility: $16,150 - Family out-of-pocket maximum: $14,300.00 = Difference paid by the health plan:*$1,850.

*The individual is NOT responsible to pay this amount.

However, since the family incurred $3,500 in non-network expenses and nonessential health benefit costs, these costs are the family’s responsibility and do not count toward the family’s out-of-pocket maximum cap.

Total family in-network out-of-pocket costs: $14,300 + Total non-network expenses: $3,500 = Total family out-of-pocket costs: $17,800.

Voluntary insurance can help

Voluntary insurance is designed to complement an individual's major medical plan. These benefits work hand in hand with major medical plans to help make sure individuals who are sick or hurt have the funds they need to pay health-related costs their primary insurance might not cover, such as daily living expenses, like bills and groceries, as well as medical deductibles and insurance copayments, expenses major medical insurance isn’t designed to cover.