How can I use my benefits to make the most of out-of-pocket maximums?


The out-of-pocket maximum is the most you pay during a policy period (usually one year) before your health insurance begins to pay for 100% of the covered health benefits. If you have a family plan, there are likely out-of-pocket maximums for individuals on your plan as well as for your family as a whole. Additionally, your health plan may have out-of-pocket maximums for care received in-network and care received out-of-network.

Anticipating the health care services that you may need in the coming year can help you decide what health plan to enroll in and what your premium, deductible, co-payment, and out of pocket maximums will be.

Due to high out-of-pocket costs, many people don't get the health care they need. So, if you experience significant health care expenses early in your policy period, have met your deductible, and are close to reaching your in-network out-of-pocket maximum, you may want to:

  • Schedule any routine health exams, follow-up visits or medical tests that you may have been putting off.
  • Discuss and schedule any elective procedures that you and your health care provider have been considering, you may have held off scheduling some procedures because it wasn't an emergency but when you've reached your out-of-pocket maximum, it may be the right time to get things taken care of.
  • Stock up on any non-perishable medical supplies that you need on a regular basis.
  • Purchase a 90-day supply of any long-term prescriptions before your policy period ends.

To avoid unexpected costs, remember to review your Summary Plan Description, get any referrals from your health care provider, and contact your health insurance company about pre-authorization before receiving certain health care services and prescriptions.