QUESTION

I thought there was supposed to be a cap on my out-of-pocket costs, but when I look at my plan options, it looks like there is more than one cap, depending on what health care I use. How can that be?

Individuals with coverage | Coverage for Employees of a Large Employer |
ANSWER

All non-grandfathered group health plans must cap out-of-pocket costs at $9,450 for an individual plan and $18,900 for a family plan in 2024. The cap applies to essential health benefits obtained in-network.

Group health plans are allowed to separate the total cap among benefits. For example, there can be a cap on out-of-pocket costs for medical benefits and a separate cap for prescription drugs, but combined, they cannot exceed the out-of-pocket spending cap of $9,450 for an individual plan or $18,900 for a family plan in 2024. Note, however, that health plans cannot have a separate cap for mental health or substance use disorder services. (45 C.F.R. § 156.130; CMS, Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year).

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