Out of Pocket Maximums and Deductibles: What You Need to Know About ACA Health Insurance


The Affordable Care Act (ACA) has been a topic of much debate since its inception in 2010. The ACA brought about many changes to the healthcare landscape, including the creation of health insurance exchanges and the expansion of Medicaid. One of the most significant changes was the introduction of out-of-pocket maximums and deductibles.

Out-of-Pocket Maximums

An out-of-pocket maximum is the most you will have to pay for covered medical expenses in a year. This includes deductibles, copays, and coinsurance. Once you reach your out-of-pocket maximum, your insurance company will cover 100% of your covered medical expenses for the rest of the year.

In 2022, the out-of-pocket maximum for most ACA plans is $8,700 for an individual and $17,400 for a family. However, some plans have higher out-of-pocket maximums. It is important to check your plan documents to see what your out-of-pocket maximum is.


A deductible is the amount you have to pay for covered medical expenses before your insurance company starts to pay. Deductibles can vary widely from plan to plan. In 2022, the average deductible for an ACA plan is $450 for an individual and $900 for a family.

How Out-of-Pocket Maximums and Deductibles Work Together

Out-of-pocket maximums and deductibles work together to limit your financial risk for covered medical expenses. Once you reach your deductible, you will start to pay coinsurance for covered medical expenses. Coinsurance is a percentage of the cost of a covered medical expense that you have to pay. The coinsurance percentage varies from plan to plan.

Once you reach your out-of-pocket maximum, you will no longer have to pay any coinsurance for covered medical expenses. However, you may still have to pay for non-covered medical expenses, such as cosmetic surgery or dental work.


Out-of-pocket maximums and deductibles are important factors to consider when choosing an ACA health insurance plan. By understanding how these two concepts work together, you can find a plan that meets your needs and budget.

If you have any questions about ACA health insurance, please contact a licensed agent.

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