The out-of-pocket maximum is a limit on what you pay out on top of your premiums during a policy period for deductibles, coinsurance and copays. Once you reach your out-of-pocket maximum, your health insurance will pay for 100% of most covered health benefits for the rest of that policy period. The next policy period (plan year), it starts all over again - note: the policy year may not coincide with the calendar year.
Thinking ahead about the health care services that you may need in the coming year and understanding how out-of-pocket maximums work can help you decide which health plan to enroll in. Learn more.
Have you met your out-of-pocket maximum (or are you close)?
If you still have time left in your policy period (plan year) and are close to reaching your out-of-pocket maximum, you may want to:
- Schedule any 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 if they are covered by your plan.
- Purchase a 90-day supply of any long-term prescriptions before your policy period ends.
To avoid unexpected costs, remember to review your policy, certificate or plan booklet, get any referrals from your health care provider, and contact your health insurance company about preauthorization before receiving certain health care services and prescriptions. Learn more
Not all plans are the same; get to know yours It’s important to know how the out-of-pocket maximum works for your plan:
- If your plan covers only in-network provider services, then all your out-of-pocket expenditures for covered benefits will go toward your out-of-pocket maximum
- If your plan covers health service provided out-of-network, then depending on the design of the plan, you may have different out-of-pocket maximums for in-network and out-of-network services.
- If you cover a dependent or have multiple dependents under a family plan, there will be an individual out-of-pocket maximum and a family out-of-pocket maximum that is two times the individual out-of-pocket dollar maximum. A family out-of-pocket maximum adds up all the family members costs for deductibles, coinsurance and copays when calculating whether the maximum is met or not.
Generally, once an individual has reached their out-of-pocket maximum most care for that person is covered at 100% ― but, the other family members keep paying. For example, say Bob’s plan has an individual out-of-pocket maximum of $5,000 and family out-of-pocket maximum of $10,000. Bob is the first in his family to reach $5,000 in expenses. Bob won’t need to pay out-of-pocket for deductibles, copays or co-insurance for the rest of the policy year for his care; however, services for his covered spouse and child would be subject to cost sharing until either their individual out-of-pocket maximum is met or the family out-of-pocket maximum is met.
There are some plans, called “Catastrophic Plans that have a combined deductible for individuals and family members that all out-of-pocket costs when combined hit the maximum, then expenses are paid by the carrier at 100%,
- Costs for health services that are not covered or services performed by non-network providers are the patient’s responsibility to pay in full and the costs typically do not count toward the out-of-pocket maximum.