Why Do Health Insurance Out-of-Pocket Maximums Increase Each Year?
2022 Maximum Out-of-Pocket Is 37% Higher Than It Was in 2014
Fact checked by Sheeren Jegtvig
An out-of-pocket maximum is the most that an insured person will have to spend in a given year on covered, in-network essential health benefits.
The Affordable Care Act (ACA) and subsequent annual regulations set caps on how high a health plan's maximum out-of-pocket can be, but these limits tend to increase each year. This article will explain the rules that apply to out-of-pocket caps and why they tend to increase over time.
If you have a health plan that's compliant with the ACA, your out-of-pocket maximum for in-network care is no more than $9,100 in 2023. If you have more than one person covered on your plan, the combined family out-of-pocket maximum can't exceed $18,200, although the plan must have an embedded individual out-of-pocket maximum that can't exceed $9,100.
As of 2024, the limits on out-of-pocket costs will increase to $9,450 for an individual and $18,900 for a family.
The out-of-pocket limit applies to all plans in the individual/family, small group, and large group insurance markets—including self-insured group plans—as long as they're not grandfathered or grandmothered.
(Regarding grandfathered and grandmothered plans: Before the ACA changed the rules, health plans were free to set their own out-of-pocket limits as they saw fit, and plans that pre-date the ACA are allowed to continue to use their pre-ACA out-of-pocket caps.)
Large group plans and self-insured health plans are not required to cover the ACA's essential health benefits, but to the extent that they do, they cannot require the member to pay more in out-of-pocket costs than the annual maximum that applies for that year.
It's important to understand that your plan's maximum out-of-pocket can be lower than these amounts... it just can't be higher. So you might have a policy with a $1,000 deductible and a maximum out-of-pocket of $4,000. That's within the guidelines of the regulations, and is quite common, depending on the metal level of the plan or the benefits package that your employer offers.
Across employer-sponsored plans, it's common to see out-of-pocket caps that are well below the allowable maximum. But in the individual/family (self-purchased) market, there are quite a few plans that use the federally allowable maximum out-of-pocket limit.
Bronze plans often have the highest allowable maximum out-of-pocket. And catastrophic plans are required to have deductibles and out-of-pocket maximums equal to the federally allowed maximum out-of-pocket (so $9,100 in 2023, and $9,450 in 2024).
But gold plans, and platinum plans in areas where they're available, tend to have lower out-of-pocket maximums, typically quite a bit lower than the maximum allowable level. Lower out-of-pocket maximums are also built into the plan design if you have a silver plan with integrated cost-sharing reductions.
What Does Out-Of-Pocket Maximum Mean?
A plan's out-of-pocket maximum (also referred to as maximum out-of-pocket or MOOP) is the total amount that the patient would have to pay in a given year for in-network treatment that's classified as essential health benefits. If you receive care outside your plan's network, the out-of-pocket maximum can be higher, or it can be unlimited.
As long as you stay in-network, receive care that's covered under your health plan, and comply with any rules your plan might have for referrals, prior authorization, step therapy, etc., your total spending for the year will be capped at no more than $9,100 in 2023, and no more than $9,450 in 2024. That includes a combination of your
deductible (the amount you pay before most benefits kick in)
copays (the smaller amount that you pay to see a doctor, fill a prescription, visit a specialist, go to the emergency room, etc), and
coinsurance (the percentage of the claim that you pay after you've paid your deductible, but before you've met your out-of-pocket maximum).
Not all plans include all three of those areas of spending. For example, an HSA-qualified High Deductible Health Plan (HDHP) typically won't include copays, but will have a deductible and may or may not have coinsurance (in some cases, the deductible on the HDHP is the full out-of-pocket maximum, while other HDHPs will have a deductible plus coinsurance in order to reach the out-of-pocket maximum).
And catastrophic plans always have deductibles equal to the out-of-pocket maximum that HHS sets for the year.
Once you've reached the annual out-of-pocket maximum, your health plan will pay 100% of your in-network, covered costs for the remainder of the year. But if you switch plans mid-year (as a result of a qualifying event that triggers a special enrollment period), your out-of-pocket costs will start over with the new plan. And even if you keep the same plan year after year, your out-of-pocket costs will start over at the start of each year.
Out-of-Pocket Maximum Increasing Again in 2024
For 2024, the maximum allowable out-of-pocket limit will be $9,450 for an individual and $18,900 for a family.
There will continue to be numerous plans available in 2024 with out-of-pocket maximums that are well below $9,450. But no ACA-compliant plans will be able to have out-of-pocket maximums above $9,450.
For perspective, the out-of-pocket maximum in 2014—the first year that ACA-compliant plans were available—was $6,350 for an individual and $12,700 for a family. So as of 2024, the cap on out-of-pocket maximums will have increased by about 49%.
Why does the out-of-pocket maximum increase each year?
Essentially, it's a method of keeping premiums in check, and keeping up with medical inflation. Although out-of-pocket maximums have increased each year since 2014, it's possible that they could decline in a future year, if average premiums start to decline.
Starting with the 2020 plan year, HHS finalized a change in how the formula works (details are in the 2020 Benefit and Payment Parameters), which ended up making the out-of-pocket maximum 2.5% higher in 2020 than it would otherwise have been. Their intention was for that methodology to be permanent, but it was ultimately only used for two years. For 2022 and beyond, HHS has reverted to the prior formula.
HHS now uses a formula that compares the average current annual per-enrollee total health insurance premium for employer-sponsored plans with the average annual per-enrollee health insurance premium for employer-sponsored plans in 2013. This is also the approach that was used prior to 2020.
But for 2020 and 2021, HHS included premiums for individual market plans, along with employer-sponsored plans, in the calculation. The increase in out-of-pocket costs for those years would have been smaller if HHS had continued to only consider employer-sponsored plan premiums, since the average employer-sponsored plan premium was higher than the average individual market premium in 2013 (this is because the ACA's reforms were much more pronounced in the individual market; coverage in the employer-sponsored market was already guarantee-issue and typically quite robust).
In the final Notice of Benefit and Payment Parameters for 2022, HHS clarified that they were reverting to the original methodology, which excludes individual market premiums from the calculation. The result is that the cap on out-of-pocket costs was $8,700 for an individual in 2022, whereas it would have been $9,100 under the methodology that the Trump administration had implemented in 2020.
But as noted above, the cap rose to $9,100 in 2023, and will grow again, to $9,450, in 2024.
2020 Numbers
So here's how the calculation worked for 2020: We divide the average 2019 private insurance premiums (employer-sponsored and individual market) by the average from 2013. That's 6,436 divided by 4,991, which equals 1.2895. That means premiums had increased by an average of about 29% from 2013 to 2019.
HHS then multiplied the out-of-pocket maximum from 2013 ($6,350) by 1.2895 in order to increase it by about 29%. That came out to $8,188, and the result was then rounded down to the nearest $50 (under the terms of the regulations that govern this process). This resulted in $8,150 as the out-of-pocket maximum for 2020.
In a nutshell, the idea is that average private insurance premiums increased by about 29% from 2013 to 2019, so out-of-pocket maximums had to also increase by roughly the same percentage from 2014 to 2020 (because they round down, the effective increase in out-of-pocket maximums was slightly smaller).
2021 Numbers
To determine the proposed out-of-pocket maximum for 2021, HHS looked at average premiums in 2013 versus average premiums in 2020 (again including average individual market premiums as well as average employer-sponsored premiums).
The same $4,991 average premium is used for 2013, but the average for 2020 had grown to $6,759 (up from $6,436 in 2019). When we divide 6,759 by 4,991, we get roughly 1.354. That means the out-of-pocket maximum for 2021 had to be roughly 35.4% higher than it was in 2013, which would amount to $8,599.
But since they round down to the nearest $50, the maximum out-of-pocket is $8,550 (all of this is detailed in the Benefit and Payment Parameters for 2021).
2022 Numbers (Reverting to the Pre-2020 Methodology)
The CMS Office of the Actuary revised the 2013 average premium amount down to $4,883. Using the new methodology that included individual market premiums (used for 2020 and 2021), CMS came up with an average projected 2021 premium of $7,036. Using those numbers, they divided 7,036 by 4,883 and came up with 1.44.
That would have called for a 44% increase in the maximum out-of-pocket from 2013 to 2022, which is where they got the proposed $9,100 maximum out-of-pocket limit for 2022 (increasing the 2013 cap—$6,350—by 44% would have amounted to $9,144, but they round down to the nearest $50, resulting in $9,100).
The public comments on that were overwhelmingly negative, with many commenters asking HHS to revert to the prior methodology that didn't include individual market premiums.
The Biden administration took over after the 2022 payment amounts had been proposed, but before they were finalized. And when the 2022 rules were finalized, they confirmed that they had indeed reverted to the pre-2020 methodology and would continue to use it in future years.
So the average 2013 premium was increased to $5,061 (since employer-sponsored insurance was more expensive than individual market insurance in 2013). And if we only consider employer-sponsored insurance in 2021, the average premium was $6,964 (instead of $7,036 that would have applied if they had used both employer-sponsored and individual coverage). When we divide 6,964 by 5,061, we get 1.376.
So instead of a 44% increase in maximum out-of-pocket since 2013, we ended up with a 37.6% increase. If we increase the 2013 maximum out-of-pocket ($6,350) by 37.6%, we get $8,738. This is rounded down to the nearest $50, resulting in a maximum out-of-pocket limit of $8,700 for 2022. The family amount is always double the individual amount, so the cap on out-of-pocket costs for a family was $17,400 in 2022.
2023 and 2024 Out-of-Pocket Maximums
Starting with the 2023 plan year, HHS switched to publishing the out-of-pocket limits in an annual memo, instead of incorporating it into the annual Notice of Benefit and Payment Parameters. But the same methodology continues to be used to calculate the out-of-pocket caps.
For 2023, the numbers were published in late 2021, and for 2024, the numbers were published in late 2022.
This gives insurers more time to prepare, as the previous approach would typically see the numbers finalized sometime in the spring, for policies that would take effect the following January. Insurers now have more than a year between when the out-of-pocket limits (and various other coverage guidelines) are published and when the policies take effect.
Summary
Prior to the ACA, health plans were generally free to set their own out-of-pocket maximums—or to not have an out-of-pocket cap at all, if they chose that approach. But under the ACA, out-of-pocket costs must be capped, and there's a federally-defined maximum that applies each year.
The out-of-pocket cap applies to essential health benefits received in-network. And it applies to all non-grandfathered, non-grandmothered health plans in the individual/family and employer-sponsored markets.
HHS has a formula for updating that cap annually. In 2014 (the first year that ACA-compliant health plans were available), the out-of-pocket cap was $6,350 for an individual. For 2024, it will have increased to $9,450. The family out-of-pocket cap is always twice the individual cap.
A Word From Verywell
If you're offered a choice of plans by your employer, or if you're shopping for your own coverage in the exchange/marketplace, it's important to carefully consider the options available to you. It might be that the lower premiums that go along with a high-out-of-pocket plan will ultimately end up saving you money when you consider the premiums plus the out-of-pocket spending. But if you prefer a plan with lower out-of-pocket amounts, those are available too.
Read the original article on Verywell Health.
