Florida 2-15 Life, Health and Variable Annuity AgentFlorida Laws and Regulations Specific to Health InsuranceHard
A Florida resident is covered by an individual medical expense policy purchased through the Health Insurance Marketplace. They need to understand the maximum out-of-pocket (MOOP) limit. Which of the following statements is true regarding the MOOP under the Affordable Care Act (ACA) for such a plan?
- AThe MOOP limit does not include deductibles or copayments.
- BOnce the MOOP limit is reached, the plan pays 100% of covered essential health benefits for the remainder of the policy year.
- CThe MOOP limit applies per illness or injury, not annually.
- DThe MOOP limit is a fixed amount set by the insurer for all plans.
Show answer & explanationAnswer & explanation
Correct answer: B. Once the MOOP limit is reached, the plan pays 100% of covered essential health benefits for the remainder of the policy year.
Under the ACA, once an insured reaches the maximum out-of-pocket (MOOP) limit for covered essential health benefits, the plan must pay 100% of all subsequent covered essential health benefits for the remainder of the policy year. This limit includes deductibles, copayments, and coinsurance.
Why the other options are wrong
- A. The MOOP limit *does* include deductibles, copayments, and coinsurance for in-network essential health benefits.
- C. The MOOP limit applies per policy year, not per illness or injury.
- D. The MOOP limit is adjusted annually by the federal government and varies by plan type (individual vs. family), not a fixed amount set by the insurer for all plans.
ACA Maximum Out-of-Pocket (MOOP)
Under the ACA, the MOOP is the highest amount an insured must pay for covered essential health benefits in a policy year. Once reached, the plan pays 100% of subsequent covered costs.
- Includes deductibles, copayments, coinsurance
- Applies to essential health benefits
- Resets annually
- Federal limits adjusted yearly
Memory trick: MOOP is your Max Out-Of-Pocket, then the Plan Pays On-demand.