What is an out-of-pocket limit?

An out-of-pocket limit is the maximum amount you, the insured, have to pay out of pocket for health care in a given plan year. This includes deductibles, copays, and coinsurance. In Virginia, the out-of-pocket limit cannot be more than $7,350 for an individual and $14,700 for a family plan in 2021. This is a cap on your out-of-pocket costs within your health plan each year. Once your out-of-pocket costs reach this limit, your health plan will cover 100% of the cost of any further medical care you need that year. This helps protect you from unexpected costs and keeps your total health care costs manageable. Additionally, the ACA (Affordable Care Act) has placed several other limits on out-of-pocket costs such as cost sharing reductions for those who make less than 250% of the federal poverty line. Any amount of money that is paid out-of-pocket, including deductibles, coinsurance, and copays, will count toward your out-of-pocket limit. Make sure to keep track of your out-of-pocket expenses throughout the year to stay within this limit.

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