Once an insured reaches the plan's annual out-of-pocket maximum under an ACA-compliant health plan, the plan generally:

Why C is correct

The out-of-pocket maximum is the annual cap on the insured's own cost sharing, which includes deductibles, copayments, and coinsurance, for covered in-network essential health benefits. Once that limit is reached, the plan pays 100% of covered in-network benefits for the rest of the year. Premiums do not count toward the out-of-pocket maximum. This cap is a core consumer protection under the ACA and applies to both individual and group health plans. The out-of-pocket maximum is the total annual ceiling on the insured's deductible, copayments, and coinsurance for covered in-network essential health benefits. Once the ceiling is reached, the plan absorbs 100 percent of covered costs for the remainder of the benefit year, protecting the insured from catastrophic spending.

Why the other options are wrong

• D) The deductible is absorbed within the out-of-pocket maximum; reaching the cap does not restart the deductible. The deductible cannot restart after the out-of-pocket maximum is met; re-imposing it would defeat the statutory cap on cost sharing for covered in-network services.
• A) Reaching the cap increases the plan's payment obligation to 100%; it does not stop coverage. Coverage continues for the remainder of the benefit year at 100 percent of covered in-network costs; stopping coverage entirely is not a consequence of reaching the cap.
• B) The insured does not need to reapply; the policy continues under its normal terms for the plan year. No reapplication is required because the out-of-pocket maximum is a benefit design feature that ends cost sharing, not an eligibility event that triggers new enrollment.

Memory hook

Hit the out-of-pocket cap and the plan pays 100% for the rest of the year. Premiums don't count toward it.