Out-of-Pocket Maximum
Most you pay for covered services in a year. Includes deductible, copays, coinsurance. Once hit, insurance pays 100% rest of year.
What You Need to Know
Out-of-pocket maximum (OOP max) is the most you'll pay for covered healthcare in a year. Once reached, insurance pays 100% of covered services for remainder of year.
What counts toward OOP max:
- Deductible payments
- Copays
- Coinsurance
- Some plans include prescriptions
What doesn't count:
- Monthly premiums
- Out-of-network care (unless plan covers it)
- Non-covered services
- Costs above "reasonable and customary" limits
2024 limits:
- Individual: $9,450 maximum
- Family: $18,900 maximum
- Most employer plans have lower limits ($5,000-8,000)
Example year:
- OOP max: $6,000
- Jan-March: Pay $2,000 deductible
- April-July: Pay $4,000 in coinsurance (20% of $20,000 in care)
- Total paid: $6,000 (hit OOP max)
- August-December: All covered care is $0
This protects you from catastrophic costs. $500,000 cancer treatment = you pay OOP max ($6,000), insurance covers remaining $494,000.
Sources & References
This information is sourced from authoritative government and academic institutions:
- healthcare.gov
https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/
Related Calculators & Tools
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Related Terms in Healthcare
Coinsurance
Percentage of medical costs you pay after meeting deductible. 20% coinsurance on $1,000 bill = you pay $200, insurance pays $800.
Copay (Copayment)
Fixed dollar amount paid for doctor visits, prescriptions, or services. $30 specialist visit copay means you pay $30, insurance covers rest.
FSA (Flexible Spending Account)
A pre-tax account for medical expenses that must be used within the plan year or you lose the money (use-it-or-lose-it rule).
In-Network
Doctors and hospitals contracted with your insurance for pre-negotiated rates. Lower costs, higher coverage. Always use in-network when possible.
Out-of-Network
Doctors not contracted with your insurance. Higher costs, lower coverage, potential balance billing. Avoid except emergencies.