Out-Of-Pocket Maximum

DEFINITION

The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits (These "benefits" include outpatient care, ER services, hospitalization, surgeries, and many more types of service. For a complete list, check out the Medical Coverage page in our Use Your Health Insurance section). The out-of-pocket maximum includes deductibles, co-insurance, copayments, or similar charges and any other costs someone needs to pay for a qualified medical expense. This limit does not have to include premiums or spending for non-essential health benefits.

EXAMPLE

The maximum out-of-pocket cost limit is different for each plan. For more information, see your insurance card, or call your insurance companies customer service line.