Q: I did the math and it seems like a family of four (two adults age 40) and two children would pay about $12,000 a year in premiums for a silver plan, along with 70 percent of the medical costs and $1000 to $3,000 deductibles. ThatÂ’s a lot of money. I heard there are limits on how much you have to spend on premiums and out-of-pocket expenses. Can you explain?
A: The law limits the percentage of your income that you have to spend on premiums, as well as the amount you have to spend out-of-pocket on deductibles and cost sharing.
The premium limits vary from 2 percent to 9.5 percent, depending on income. Out-of-pocket expense limit, which changes each year; will be $6,350 for an individual and $12,700 for a family in 2014.
Out-of-pocket expenses include money spent on reaching your deductible and cost sharing (coinsurance and co-pays) but not premium costs. This applies to individual plans sold both inside and outside the exchange.
Q: Can you give me an example of how the out-of-pocket cap works?
A: Say you have a plan with a $2,500 deductible. You fall off your skateboard and break a lot of things you think you might need later on in life.
If you have a “silver” level plan that pays 70 percent, you’ll pay 30 percent of your $50,000 hospital bill — you needed lots of fixing — until you’ve paid out $6,350, which is your (maximum out-of-pocket for the year).
Insurance kicks in at that point. You still have to pay the premiums, but you’re done paying health care expenses — so long as they are for “essential health benefits” — for the year.