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What is the out-of-pocket maximum I have to pay?

The out-of-pocket maximum is a limit on what you will pay for covered medical services in a policy period (usually one year), regardless of how high your medical bills are. After you reach your out-of-pocket maximum, your insurance plan will pay 100 percent of your medical expenses. Your out-of-pocket maximum includes your yearly deductible and may also include any cost sharing you have after the deductible. It may not include premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, as well as spending on care not covered by your plan (frequently dental or vision care), or spending for what the insurer considers non-essential health benefits. (Your insurer, for example, may determine that a test your doctor recommended is not essential, which is why MRIs and other expensive tests often require pre-authorization.)

In 2016, the maximum out-of-pocket limit for any individual Marketplace plan is $6,850 for an individual plan and $13,700 for a family plan.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.