When choosing a health plan, a term that might come up is out-of-pocket maximum.
An out-of-pocket maximum is the most you’ll have to pay during a policy period for health care services. Once your medical expenses add up to your out-of-pocket maximum, your health plan will cover 100 percent of the allowed amount for covered services.
For example, if you have a health plan with a $6,000 out-of-pocket maximum, when your health costs (deductible, copays and coinsurance) have reached that amount, your health insurance company will cover all health services you will need for the rest of the policy period (in most plans, the policy period is a year).
If you have a $3,000 deductible, first all payments you make will go toward your deductible. After your deductible has been met, all copays and coinsurance costs will go toward your out-of-pocket max.
What type of payments you make go toward your out-of-pocket max?
- Your deductible
- Copays
- Your coinsurance
What type of payments DO NOT go toward your out-of-pocket max?
- Your monthly premiums
- Any service that your health plan does not cover
If you have a family health plan, your out-of-pocket maximum will be higher than if you had an individual health plan. Also, your health plan covers out-of-network services, the out-of-pocket max might be different from your in-network out-of-pocket max. You should contact your health insurance and ask for my details. You may also refer to your Summary of Benefits and Coverage.
Need more information on out-of-pocket max? Please contact us and we’ll be happy to help you.