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What Does Health Insurance Out of Pocket Maximum Mean


What Is an Out-of-Pocket Maximum?

An out-of-pocket maximum is a limit on the amount of money you have to pay for covered health care services within a plan year.

Once you reach this limit, your health plan will pay 100% of all covered health care costs for the remainder of the plan year.

Some health insurance plans refer to this as an out-of-pocket limit. A plan year typically lasts for 12 months, from the effective date of your coverage to the date it ends.

How Does an Out-of-Pocket Maximum Work?

Any costs you pay for covered health care services count toward your out-of-pocket maximum. This includes expenses that contribute to your plan deductible, as well as coinsurance and copays for doctor visits.

Example of How an Out-of-Pocket Maximum Works

Let’s consider an example to understand how an out-of-pocket maximum functions within a health plan:

  • Jane Q. has a health plan with a $2,500 deductible, 20% coinsurance, and a $4,000 out-of-pocket maximum.
  • At the beginning of her plan year, Jane falls ill unexpectedly. She sees her regular doctor and several specialists, and undergoes numerous medical tests. The total bill amounts to $2,500, which she pays, thus meeting her deductible. This payment also counts toward her out-of-pocket maximum.
  • Throughout the year, Jane continues to see specialists and undergoes additional tests, incurring bills totaling $1,500. Since her plan has a 20% coinsurance, Jane pays $300 (20% of $1,500), and her health plan covers the remaining $1,200. These payments contribute to her out-of-pocket maximum.
  • At this point, Jane has spent a total of $4,000, meeting her out-of-pocket maximum. For the remainder of the plan year, her health plan will cover 100% of her costs for covered care.

What Counts Toward an Out-of-Pocket Maximum?

Health care expenses that typically count toward an out-of-pocket maximum include:

  • Deductibles: Costs paid out of pocket that contribute to your deductible, usually for covered, non-preventive, in-network care.
  • Coinsurance: Your share of costs after meeting the deductible, which also goes toward the out-of-pocket maximum.

Expenses That Don’t Count Toward the Out-of-Pocket Maximum

Some expenses may not count toward the out-of-pocket maximum, such as:

  • Uncovered Services: Services not covered by your plan, like cosmetic treatments or weight loss surgery.
  • Costs Above Allowed Amounts: Charges exceeding the plan’s set amounts for services.
  • Out-of-Network Care: Care from providers outside your plan’s network.
  • Plan Premiums: Monthly premiums for the plan.
  • Most Preventive Care: Covered at 100% by many plans, as mandated by the Affordable Care Act (ACA).
  • Plan Deductibles (in Some Cases): In certain plans, costs toward the deductible may not count toward the out-of-pocket maximum.

Do All Health Plans Have an Out-of-Pocket Maximum?

Plans complying with ACA standards must have out-of-pocket maximums. However, non-ACA plans may not adhere to the same requirements.

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Individual vs. Family Out-of-Pocket Maximums

Health insurance plans covering multiple individuals often have both individual and family out-of-pocket maximums:

  • Individual Out-of-Pocket Maximum: When an individual reaches this limit, the plan pays 100% of their covered care for the rest of the plan year. Any expenses individuals pay also contribute to the family out-of-pocket maximum.
  • Family Out-of-Pocket Maximum: Costs for each individual count towards this limit, including deductibles, coinsurance, and copays. Once the family maximum is met, the plan covers 100% of everyone’s covered costs for the remainder of the plan year.

Affordable Care Act and Out-of-Pocket Maximums

For plans purchased independently (not through an employer), there are set limits for these out-of-pocket maximums, as mandated by the Affordable Care Act (ACA).

Do Most People Meet Their Out-of-Pocket Maximum?

Meeting the out-of-pocket maximum depends on your health needs:

  • Healthy Individuals: Those who mainly require routine care may not meet their deductible, as preventive care is often fully covered by the plan.
  • High Medical Needs: Individuals requiring extensive medical care could reach their out-of-pocket maximum due to accumulated medical bills.

Understanding Your Health Plan

It’s essential to comprehend how the out-of-pocket maximum interacts with other aspects of your health plan, such as the deductible, coinsurance, and copays. When selecting a health plan, consider your anticipated health needs alongside these factors.


Differentiating between individual and family out-of-pocket maximums is crucial for understanding your health insurance coverage. Knowing these limits and how they apply to your plan can help you make informed decisions about your health care.


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