Health Plans Fail to Meet ACA Standards for Out-Of-Pocket Spending

Thirty-six percent of health insurance plans would exceed even most permissive ACA plan limits on out-of-pocket expenses for consumers, according to an analysis from HealthPocket. In addition, 38% of plans did not disclose their deductible within its annual out-of-pocket limits, concealing the full amount a person could pay if the Summary of Benefits was not read carefully.

These plans will have to adopt more transparency by 2014 when the Affordable Care Act (ACA) provisions go into effect. Many will also need to reduce the out-of-pocket burden on their customers to meet even the most basic plan options under health reform. Beginning in 2014, insurers must offer plans that fit within four levels of coverage: Bronze, Silver, Gold, and Platinum. Most Americans will be required to purchase at least a Bronze-level plan, which has the highest out-of-pocket option for the consumer. The new ACA plans would cap current out-of-pocket costs to $6,250 per calendar year. When plan deductible amounts were taken into account, 36% of all health plans had higher out-of-pocket limits than what Bronze Plans will permit. There will be protections to limit how much consumers pay out-of-pocket, but many plans are clearly failing to meet these guidelines, and insurance coverage is inconsistent depending on where plans are sold.

Kev Coleman, head of research & data at HealthPocket said, “The Affordable Care Act’s limit on out-of-pocket costs will have a highly regional impact, with consumers in states, such as Vermont, Alabama, and Florida reaping the biggest benefits. While the average out-of-pocket costs limit nationwide falls within ACA guidelines, there are still thousands of plans that need to improve their out-of-pocket costs for 2014.”

The national average for out-of-pocket limits was $6,019 when the deductible was included in out-of-pocket costs for all plans. While the national average is below the Bronze Plan average, state averages varied from $3,192 to $10,013. Nationally, only 4% of plans examined had no limits on how much a consumer could pay annually in out-of-pocket spending for healthcare. When there is no annual out-of-pocket limit, a severe medical episode could result in catastrophic expenses even with health insurance coverage. Lab tests, hospitalization, surgery, could lead to expenses above $100,000 with out-of-pocket expenses on some plans representing 30% or more of these costs. Results of this study were based on an analysis of 9,752 health insurance plans for people and families under the age of 65. For more information, visit

Last Updated 06/29/2022

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