Do premiums count toward the out-of-pocket maximum in ACA plans?

• A. Premiums do not count toward the out-of-pocket maximum.
• B. Premiums count toward the out-of-pocket maximum.
• C. Only part of the premium counts toward the out-of-pocket maximum.
• D. Premiums count only if you are enrolled in a Platinum plan.

Answer: (A)

The amount that counts toward the out-of-pocket maximum is the money you spend on covered medical services in a year, such as deductibles, copays, and coinsurance for in-network essential health benefits. Premiums, the monthly payments you make to maintain your coverage, are separate and do not reduce or count toward that limit. So even though you pay premiums to stay insured, they don’t contribute to reaching the out-of-pocket maximum. Once your covered costs for the year hit the limit, the plan pays 100% of remaining covered costs for that year, but you’ll still owe your ongoing premiums.