Starting Out With Out-of-Pocket Maximum
Out-of-Pocket Maximum: the few things that matter most, and the mistakes that catch people out early.
The most you have to pay for covered, in-network services in a plan year, after which your plan pays 100 percent of covered costs.
Key takeaways
- What counts toward it: deductibles, copays and coinsurance for covered in-network services
- What does not count: monthly premiums, out-of-network care and services the plan does not cover
- Most useful single change: Look up your plan's individual and family out-of-pocket maximum before the year starts.
- Commonest mistake: Assuming premiums count toward the out-of-pocket maximum.
- See a doctor if any of the signs under "When to speak to a doctor" below apply to you.
Why bother
It is the number that protects you in a bad year, so it tells you more about your worst-case costs than the premium does.
Start here
Two to start. There is no prize for doing all of it in week one.
- Look up your plan's individual and family out-of-pocket maximum before the year starts
- Keep track of what you have paid; your plan portal or Explanation of Benefits shows progress
Then add these
The next additions, when you are ready for them.
- If you have met the limit, schedule needed covered care before the plan year resets
- Choose in-network providers so your spending counts toward the cap
The numbers, in one place
| Measure | Figure |
|---|---|
| What counts toward it | deductibles, copays and coinsurance for covered in-network services |
| What does not count | monthly premiums, out-of-network care and services the plan does not cover |
| After you reach it | the plan pays the full cost of covered in-network services for the rest of the plan year |
| Federal limit | Marketplace and most other plans have a cap set each year by federal rules |
| Family plans | have both an individual and a family out-of-pocket limit |
Common early mistakes
- Assuming premiums count toward the out-of-pocket maximum
- Using out-of-network care and expecting it to count toward your in-network limit
- Forgetting that the limit resets at the start of each plan year
Related topics
- The Evidence on Medicare Advantage Plans, Without the Hype (Medicare and Medicaid)
- The Evidence on Travel Insurance and Healthcare Abroad, Without the Hype (Travel Health)
- Sexual Health Services: What Published Guidance Supports (Sexual Health)
- What the Guidance Really Says About Benefits and Financial Support (Long-Term Conditions)
Where to go next
- Out-of-Pocket Maximum: Common Myths and What Guidelines Say
- Answers to the Common Questions on Out-of-Pocket Maximum
- Out-of-Pocket Maximum — the reference entry
- Health Insurance: The Complete Guide
- What the Guidance Really Says About In-Network and Out-of-Network Care
- What the Guidance Really Says About Reading an Explanation of Benefits
When to speak to a doctor
If you have a serious or ongoing condition, check your plan's out-of-pocket maximum and network carefully with your doctor's office. Do not put off urgent or emergency care because of cost; call 911 for a medical emergency.
Where this comes from
- HealthCare.gov — Out-of-pocket maximum/limit
- HealthCare.gov — Health insurance basics
How this page was put together
Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.
Medical disclaimer
This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.
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