Real answers for your healthcare questions
What is an out of pocket maximum and what counts toward it?
Answer
The out of pocket maximum is the most you generally have to pay in a plan year for covered in network essential health benefits under many health plans. After you reach it, the plan typically pays 100 percent of covered in network costs for the rest of the plan year.
What to Know
Amounts that commonly count include deductibles, copays, and coinsurance for covered in network care. Premiums generally do not count. Out of network spending or services the plan does not cover may also be excluded, depending on the plan.
What to Do Next
Find the out of pocket maximum in your plan documents and confirm what counts toward it. If you expect significant healthcare use, this number can be just as important as the monthly premium.
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