Out-of-Pocket Maximums Explained
What is an out-of-pocket maximum?
The out-of-pocket maximum is the most you would pay for covered services in a plan year. Once you reach it, the plan generally pays 100% of covered in-network services for the rest of the year. Premiums do not count toward it.
If the deductible describes the beginning of a difficult year, the out-of-pocket maximum describes the ceiling of one.
Deductibles, copays and coinsurance for covered in-network services typically count toward it. Premiums do not, and neither do charges for services the plan does not cover.
For anyone weighing financial risk, this number often matters more than the deductible.
Important exceptions
- Out-of-network care may have a separate, higher maximum or none at all.
- Non-covered services and balance billing generally do not count toward the maximum.
- Family plans handle individual and family maximums differently.
Dave's perspective
“I ask people to look at the out-of-pocket maximum and honestly answer one question: if this year went badly, could I handle that number? That is the real risk conversation.”
Dave Gagleard · Dave Knows Health
Related information
Plan availability, eligibility, benefits, exclusions, underwriting requirements, enrollment periods and coverage vary by carrier, product and state.