The out-of-pocket maximum/limit is the amount you are required to pay for covered services within a specific plan year. Once you reach this limit by paying deductibles, copayments, and coinsurance for in-network care and services, your health plan covers 100% of the costs for covered benefits. The out-of-pocket limit does not include monthly premiums, expenses for services not covered by your plan, out-of-network care and services, or costs exceeding the allowed amount for a service that a provider may charge.
- The out-of-pocket maximum is the most you will have to spend on healthcare expenses in a given plan year, ensuring a financial cap on your healthcare costs.
- Covered expenses include deductibles, copayments, and coinsurance for in-network care and services.
- The out-of-pocket limit does not cover premiums, non-covered services, out-of-network care, or charges exceeding the allowed amount.
- The specific out-of-pocket maximum may vary by year and is regulated, but it cannot exceed a set amount. Click here if you have the question, What is an example of an out-of-pocket maximum?