Out-of-pocket Maximum

The money that you must pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit, the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges, or health care your plan doesn’t cover. Some plans don’t count all of your co-payments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. See a detailed example.