How do out-of-pocket maximums work?

Who is this for?

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Anyone under age 65.

You share the cost of your care with your health insurance company when you pay your deductible, coinsurance and copays. But did you know there’s a limit to how much you pay? It’s called an out-of-pocket max, or maximum.

It’s the most you’ll have to pay during a policy period, usually a year, for health care services.

How it works

What you pay toward your plan’s deductible, coinsurance and copays are all applied to your out-of-pocket max.

Once you reach your out-of-pocket max, your plan pays 100 percent of the allowed amount for covered services.

If your plan covers more than one person, you may have a family out-of-pocket max and individual out-of-pocket maximums. That means:

  • When the deductible, coinsurance and copays for one person reach the individual maximum, your plan then pays 100 percent of the allowed amount for that person
  • When what you’ve paid toward individual maximums adds up to your family out-of-pocket max, your plan will pay 100 percent of the allowed amount for health care services for everyone on the plan

What doesn’t go toward your out-of-pocket max

  • Amounts you pay for health care services that aren’t included in your plan’s benefits
  • Your monthly payment, or premium, if you buy your own health insurance

Dental plans are different

Out-of-pocket maximums for dental plans also limit what you pay in deductible, coinsurance and copays. But dental plans usually only have an out-of-pocket max for members age 19 and younger.